Routine Use of Immunosuppressants is Associated with Mortality in Hospitalised Patients with COVID-19
Abstract Background: Whilst there is literature on impact of the SARS viruses in the severely immunosuppressed, and those who develop exaggerated immune response, less is known about the link between routine immunosuppressant use and outcome in COVID-19. Consequently, guidelines on their use vary depending on specific patient populations.Methods: The study population was drawn from the COPE Study (COVID-19 in Older People), a multicentre observational cohort study, carried out in UK and Italy. Data were collected between 27th February and 28th April 2020 by trained data collectors and included all unselected consecutive admissions with Covid-19. Load (name/number of medications) and dosage of immunosuppressant were collected along with other covariate data. The primary outcome was time-to-mortality from the date of admission (or) date of diagnosis, if diagnosis was five or more days after admission. Secondary outcomes were Day-14 mortality and time-to-discharge (length of stay). Data were analysed with mixed-effects, Cox proportional hazards and Logistic regression models using non-users of immunosuppressants as the reference group.Results: 1184 patients were eligible for inclusion. The median (IQR) age was 74(62-83), 676(57%) were male, and 299(25.3%) died in hospital (total person follow-up 15,540 days). Most patients exhibited at least one comorbidity, and 113(~10%) were on immunosuppressants. We found that any immunosuppressant use was associated with increased mortality: aHR 1.87,95%CI:1.30,2.69 (time to mortality) and aOR1.71,95%CI:1.01-2.88 (14-day mortality). There also appeared to be a dose-response relationship.Conclusion: Despite the possibility of indication bias, until further evidence emerges we recommend adhering to public health measures stringently, a low threshold to seek medical advice and close monitoring of worsening symptoms in those who take immunosuppressants routinely regardless of their indication.