Background/Purpose: Immunosuppression for treatment of systemic autoimmune rheumatic diseases (SARDs) is associated with increased risk of severe acute COVID-19 due to blunted vaccine responses and impaired immune response to infection. Whether immunosuppression may also alter the risk for post-acute sequelae of COVID-19 (PASC), or “long COVID,” is unclear. Previous studies (Al-Aly et al, Nature Medicine, 2022) have developed electronic health record (EHR)-based definitions of PASC that have the benefit of including all COVID-19 survivors, rather than relying on prospective studies that may have selection bias, but have not been performed among SARD patients. We evaluated baseline demographic and disease factors associated with PASC in a large EHR-based cohort of patients with SARDs.

Methods: We systematically identified patients with SARDs and confirmed COVID-19 in a large healthcare system (up to 1/18/2023). We required patients to have baseline data in the EHR prior to the index date, defined as initial COVID-19 infection. Patients who survived COVID-19 were followed from 30 days after the index date until the development of any incident PASC feature, repeat COVID-19 infection, 1 year of follow-up, death, or until 4/14/2023. We evaluated the proportion with incident PASC features, defined by incident ICD codes, relevant vital signs or labs, and/or medications, extracted from the EHR. We estimated the association of baseline characteristics with the risk of PASC using multivariable Cox regression.

Results: We identified 2,459 patients with SARDs and confirmed COVID-19 (76% female, mean age 57 years, Table 1). The majority of patients (1566; 64%) had at least one incident feature of PASC. The most common incident PASC features were hyperlipidemia (561; 23%), anxiety (419; 17%), dyspnea (303; 12%), fatigue (263; 11%), and chest pain (246; 10%) (Figure). Compared to antimalarial monotherapy, TNF inhibitors were associated with lower PASC risk (aHR 0.78, 95% CI 0.64-0.94) and CD20 inhibitors were associated with higher PASC risk (aHR 1.27, 95% CI 1.02-1.59) (Table 2). Glucocorticoid use (vs. non-use) was associated with higher PASC risk (aHR 1.15, 95% CI 1.02-1.29). Compared to those with COVID-19 infection early in the pandemic, those with infection during the Delta wave (aHR 0.59, 95% CI 0.46-0.76) and Omicron era (aHR 0.51, 95% CI 0.41-0.63) had a lower risk of PASC. Older age, Black race, increased comorbidity burden, hospitalization for acute COVID-19 infection, and diagnosis of SLE or ANCA-associated vasculitis (compared to RA) were also associated with higher PASC risk.

Conclusion: Among patients with SARDs, CD20 inhibitor users had a higher PASC risk while TNF inhibitor users had a lower PASC risk following COVID-19 infection, suggesting that baseline immunosuppression may alter the post-acute COVID-19 course. Other factors associated with PASC included SLE or ANCA-associated vasculitis, as well as general population risk factors including calendar time (as a marker of SARS-CoV-2 variant and available treatments), older age, race, and hospitalization for acute COVID-19. These findings emphasize the potentially large burden of PASC among patients with SARDs.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/factors-associated-with-an-electronic-health-record-based-definition-of-post-acute-sequelae-of-covid-19-in-patients-with-systemic-autoimmune-rheumatic-diseases/