2228: COVID-19 Outcomes in Rheumatoid Arthritis Patients Prescribed Biologic vs. Conventional DMARDs: A Propensity-Matched Analysis

Background/Purpose: Rheumatoid Arthritis (RA) is an autoimmune disease characterized by immune system dysregulation, and it is commonly treated with either conventional or biologic Disease-Modifying Antirheumatic Drugs (DMARDs). Because RA and its therapies suppress the immune system, patients are more susceptible to infections, including COVID-19. However, it remains unclear whether conventional DMARDs or biologic DMARDs confer some benefit with respect to COVID-19 outcomes. This study aims to compare COVID-19 outcomes in RA patients treated with biologic versus conventional DMARDs. We hypothesize that the broader, less targeted immunosuppressive effects of conventional DMARDs may play a more protective role for patients who develop COVID-19 infections.

Methods: The TriNetX Database was queried to identify patients ≥ 18 years old with RA and a COVID-19 diagnosis. These individuals were then divided into two subgroups: those prescribed biological DMARDs (adalimumab, etanercept, infliximab, rituximab, and tocilizumab, n=4,166) and those who were prescribed conventional DMARDs (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, and azathioprine, n=35,792) within 1 year of the COVID-19 diagnosis. These groups were 1:1 propensity score matched (n=4,163) for demographics and relevant comorbidities. Primary outcomes included 30-day, 90-day, and 1-year medical complications following a COVID-19 diagnosis, and these were compared using risk ratios (RR) with statistical significance set to p< 0.05.

Results: RA patients prescribed biological DMARDs before COVID-19 diagnosis had a significantly higher 30-day risk of ventilator use (RR=2.295, p< 0.001), mortality (RR=1.907, p< 0.001), and pulmonary fibrosis (RR=2.389, p=0.001), an increased 90-day risk of ventilator use (RR=2.092, p< 0.001), mortality (RR=1.819, p< 0.001), and pulmonary fibrosis (RR=2.528, p< 0.001), and an increased 1-year risk of ventilator use (RR=2.076, p< 0.001), mortality (RR=1.726, p< 0.001), and pulmonary fibrosis (RR=2.137, p< 0.001).

Conclusion: Our study suggests that patients with RA taking biological DMARDs have worse COVID-19 outcomes than those taking conventional DMARDs. Patients receiving conventional DMARDs required less ventilatory support during COVID-19 infection, indicating a milder disease course. This may be attributed to the less specific immunosuppressive mechanism of conventional DMARDs when compared to the more targeted mechanism of biological DMARDs, which potentially could lead to a weaker immune response against COVID-19.