Table 3.
Immunosuppressants and the risk of severe COVID-19 outcomes in patients with either immune-mediated diseases or transplantation
| Drugs | Risk of severe COVID-19 (including death) outcomes |
|---|---|
| Steroids | ≥10 mg/day [OR 1.76 (95% CI 1.06–2.96)] [4] 1–10 mg/day [OR 1.69 (95% CI 1.11–2.57)] [2] ≥10 mg/day [OR 1.93 (95% CI 1.11–3.36)] (international registry/CTD and vasculitis) [2] ≥10 mg/day [OR 2.8 (95% CI 1.36–5.79)] [international registry (AAV)] [3] Chronic corticosteroids [OR 1.89 (95% CI 1.43–2.49)] (transplant/autoimmunity) [41] corticosteroids [OR 1.97 (95% CI 1.09–3.54)] (rheumatic diseases) [42] |
| Mycophenolic acid | RR 3.94 (95% CI 1.59–9.74) (liver transplantation) [43] OR 6.6 (95% CI 1.47–29.62 (rheumatic diseases) [42] |
| Azathioprine | OR 1.10 (95% CI 0.54–2.24) [international registry (AAV)] [3] |
| Calcineurin inhibitors | HR 0.55 (95% CI 0.31–0.99) (tacrolimus, liver transplant) [44] OR 1.19 (95% CI 0.65–2.20) (CNIs, transplant/autoimmunity) [41] |
| CD20-depleting agents | OR 3.72 (95% CI 1.21–11.48) (international registry/CTD and vasculitis) [2] OR 2.15 (95% CI 1.15–4.01) [international registry (AAV)] [3] OR 4.21 (95% CI 1.61–10.98 (rheumatic diseases) [42] Effect size 3.26 (95% CI 1.66–6.40) (rheumatic diseases) [40] |
| Belimumab | OR 1.07 (95% CI 0.21–5.37) (international registry/CTD and vasculitis) [2] |
| Alkylating agents (i.e. cyclophosphamide) | OR 4.30 (95% CI 1.10–16.75) [international registry (AAV)] [3] |
| Complement inhibitors | No data |
All information provided here is based on observational and retrospective data. The association between higher doses of steroids and risk to develop severe COVID-19 was confirmed not only in autoimmunity or transplantation, but most investigations found only a modest and non-significant increased risk when patients received a steroid dose <10 mg/day. Multiple independent investigations found an association between rituximab use and severe COVID-19. In addition, a combination of different strategies might also portend a higher risk (as seen in transplantation). Notably, the ‘international registry’ [2] included a similar set of patients. For specific references see the Supplementary data, online Appendix. CNI, calcineurin inhibitor; CTD, connective tissue disease; OR, odds ratio; CI, confidence interval; RR, relative risk.