Exposure to systemic corticosteroids is associated with an increased risk of COVID-19 infection and consequent severe outcomes in patients using immunosuppressive therapy for non-infectious uveitis (NIU), according to a large cohort study published in Ophthalmology.
Between January 20, 2020 and December 31, 2020, researchers conducted a retrospective study of patients with NIU (n = 52,286) using the Optimum Labs Data Warehouse, a national database of unidentified claims in the U.S. They estimated the unadjusted and adjusted hazard ratios for each variable and the outcome of COVID-19 using Cox proportional hazard models, with dichotomous indicators updated over time for outpatient exposure to immunosuppressive drugs. To assess the dose-dependent influence of systemic corticosteroid exposure, the mean daily dose (mg) of prednisone covering the exposed range was included in the adjusted models as a continuous variable as well as the dichotomous variable.
The main outcome measures of the study were the incidence rates of COVID-19 infection, COVID-19-related hospitalization, and COVID-19-related in-hospital death. The mean age of the patients in the global cohort was 62.8 years (60.3% women, 39.6% men, 0.1% unknown).
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Of the 52,286 NIU patients, 9,516 patients (18.2%) were exposed to systemic corticosteroids during the risk period. In total, 9,516 users filled 22,948 systemic corticosteroid prescriptions, with a mean duration of 24 days and an average duration of 14 days (interquartile range 6-30 days). The most prescribed systemic corticosteroid was prednisone, which included 72.4% of SC prescriptions during the risk period.
According to the adjusted models, exposure to systemic corticosteroids was associated with a higher risk of COVID-19 infection (hazard index). [HR]= 2.66; 95% CI: 2.19–3.24; P <, 001), hospitalization (HR = 3.26; 95% CI: 2.46-4.33; P <, 001) and in-hospital death (HR = 1.99; 95% CI: 0.93-4 , 27; P = .08). The researchers found that incremental increases in systemic corticosteroid dose were associated with an increased risk of these outcomes. Tumor necrosis factor alpha (TNF-α) inhibitors were associated with an increased risk of infection (HR = 1.48; 95% CI: 1.08–2.04; P = 0.02). while other immunosuppressive treatments did not increase the risk of COVID-19. infection, hospitalization or death.
In both unadjusted and adjusted tests, elderly patients of black and Hispanic ethnicity had a higher risk of infection, hospitalization, and hospital death due to COVID-19. In multivariate analyzes, comorbidities such as cardiovascular disease, chronic kidney disease, neurological disease, and diabetes showed associations with each COVID-19-related outcome.
“Ophthalmologists currently providing care to these patients should think of ways to reduce their patients’ risk of exposure or serious illness by promoting the use of masks and vaccination, ”the researchers explain. “Physicians may also consider clinical interventions to reduce the risk of COVID-19 exposure for patients with systemic corticosteroids, such as dedicated time slots for immunosuppressed patients or telehealth monitoring for patients with stable disease.”
The limitations of the study include a skewed population toward elderly patients, the possibility that all aspects of uveitis disease status may not be considered, the possibility of misclassification of COVID-19 infection, and the exclusion of people with basic Medicare, Medicaid, or uninsured plans. In addition, the observed exposure period may not fully characterize the actual exposure period, possible confounding factors were only captured at baseline, and some specific drug classes were not analyzed separately due to of the limited sample size in these subgroups. Finally, lab testing at Optum Labs Data Warehouse is only available through lab vendors who contract with the insurer, who probably underestimated the correct number of positive COVID-19 tests.
Reference
Sun Y, Miller DC, Akpandak I, Chen EM, Arnold BF, Acharya NR. Association between immunosuppressive drugs and COVID-19 outcomes in patients with non-infectious uveitis in a large U.S. claims database. Ophthalmol. Published online May 16, 2022. doi: 10.1016 / j.ophtha.2022.05.008
This article originally appeared in Ophthalmology Advisor