New findings published in Investigative Ophthalmology & Visual Science assessed the potential connection between patients with noninfectious uveitis (NIU) with an increased risk of COVID-19 infection, hospitalization, and death.
Give me some background first.
NIU is inflammation in the eye that may sometimes be related to other autoimmune diseases, potentially leading to loss of vision in severe cases if untreated.
The disease is typically treated with immunosuppressive medications such as corticosteroids or disease-modifying anti-rheumatic drugs (DMARDS). Medication may be taken over longer periods of time when uveitis is chronic.
Go on…
Despite its effectiveness in reducing inflammation, these immunosuppressants could potentially increase the risk of infection. As the immunocompromised are more susceptible to COVID-19 infection, this has become a topic of rising concern in light of the COVID-19 pandemic.
A previous study, conducted prior to the availability of COVID-19 vaccines, illustrated that systemic corticosteroids (SCs) were associated with increased risk of COVID-19 infection.
With the emergence of COVID-19 vaccines, the study authors aimed to investigate the association between SCs and severe COVID-19 in patients with NIU.
Now, talk about the study.
Data from July 1, 2021, to June 30, 2022, was acquired from Optum Labs Data Warehouse. Patients with NIU were identified using ICD-10 codes. Patients who developed NIU after COVID-19 were excluded, as were patients with any infectious uveitis.
Incident rates (IR) and hazard rates (HR) were calculated for exposures associated with COVID-19 infection, hospitalization, and death to compare data between vaccinated and unvaccinated patients and exposure to various immunosuppressive medications.
Which medications were analyzed?
The immunosuppressive medications categorized in the study were:
- SCs
- DMARDs
- Tumor necrosis factor-alpha (TNF-alpha)
- Interleukin-6 (IL-6)
- Other biologic immunosuppressive therapies
- Other nonbiologic immunosuppressive therapies
Out of 62,209 patients with NIU, 15,625 patients were prescribed at least one of the six immunosuppressants analyzed in the study.
SCs were the most common, comprising 20.7% of patients.
Findings?
The risk of COVID-19 infection, hospitalization, and death increased significantly in patients with NIU who were exposed to SCs. For every 10 mg increase in average daily dose of SCs, there was a 16% increased risk of infection and 17% increased risk of hospitalization for COVID-19.
An increased risk was also found in patients who took short-term and long-term low doses (0 to 10 mg/day) of SCs, suggesting that the risk of COVID-19 hospitalization may increase at low doses—regardless of duration.
What about DMARDs?
Researchers found a 3-fold increased risk of COVID-19 hospitalization in patients exposed to DMARDs. However, a definitive association between the use of DMARDs and COVID-19 hospitalization risk could not be made as this result was statistically insignificant.
The adjusted model suggested that DMARDs may protect against COVID-19, but further study is required to make associations.
How does this compare to unvaccinated patients?
The IR of COVID-19 infection increased in this study compared to the IR of the unvaccinated population, possibly due to the general increase in known cases of COVID-19, according to the study authors.
The IR of COVID-19 hospitalization and death remained similar in both studies.
Amongst patients who were exposed to SCs and not vaccinated for COVID-19, the risk of COVID-19 infection increased 2-fold, the risk of hospitalization by 5-fold, and the risk of death 3-fold.
Meaning …
Indicating that COVID-19 vaccination could possibly assist in protecting NIU patients with SC exposure from severe illness caused by COVID-19.
Any limitations?
A few… Only commercially insured patients and patients with Medicare Advantage were included in this study, and the sample may represent an older population due to the inclusion of Medicare Advantage.
As the data used in this study relied on the information recorded in Optum Labs Data Warehouse, it is unknown whether any outcomes or vaccinations statuses were misclassified.
Due to limited sample sizes, some types of immunosuppressive were unable to be analyzed.
Expert opinion?
Researchers recommend that “limiting exposure to SCs and use of alternative therapies may be prudent in patients with NIU. [...] COVID-19 vaccination should be strongly encouraged in patients taking immunosuppressive therapies.”
Take home.
This study demonstrates that patients with NIU who have been exposed to SCs remain associated with a greater risk of COVID-19 infection, hospitalization, and death with the availability of COVID-19 vaccines.
Furthermore, the findings suggest an increased risk of severe outcomes from COVID-19 for unvaccinated patients.
Additional studies could explore a more representative sample and gather greater data on other immunosuppressive drugs used to treat NIU.