Immunosuppressive Drugs for Autoimmune Disease May Reduce Risk of ARDS in COVID-19 Hospitalizations

Immunosuppressed patients who had an autoimmune disease (AD) were significantly less likely to develop severe acute respiratory distress syndrome (ARDS) compared with patients who were not immunosuppressed and did not have an AD.

Patients hospitalized for coronavirus disease 2019 (COVID-19) who receive immunosuppressive treatment for an autoimmune disease (AD) may be at lower risk for acute respiratory distress syndrome (ARDS), says a new study.

The study of nearly 800 patients found that immunosuppressed patients—defined as those taking any drug with an immunomodulatory or immunosuppressive effect –who had an AD (IS-AD) were significantly less likely to develop severe ARDS compared with patients who were not immunosuppressed and did not have an AD (NIS-NAD), with a hazard ratio (HR) of 0.42 in adjusted analyses.

Meanwhile, there was no reduction observed when it came to patients who were not immunosuppressed and had an AD (NIS-AD) (HR 0.96), and patients who were immunosuppressed but did not have an AD (IS-NAD) had an increased, although nonsignificant, risk compared with NIS-NAD patients (HR, 1.14).

“Suspension of effective immunosuppressive treatment in these patients may jeopardize AD disease control, with potentially serious consequences,” wrote the researchers based on their findings. “Such action may not be necessary; however, careful, tailored decision-making, taking into account all of an individual’s known risk factors, is critical.”

There were no significant differences in mortality between NIS-NAD patients and the other groups of patients, although the researchers did see differences in risk between patients who did not have an AD. Compared with NIS-NAD patients, IS-NAD patients had a trend toward an increased risk of death.

The researchers also did not find any significant differences between the groups as it related to requiring mechanical ventilation or non-invasive ventilation.

“Overall, these findings indicate that the relationship between immune function and COVID-19 outcomes is highly complex, and warrants further investigation,” wrote the researchers, who noted that there were initially concerns that immunosuppressed patients with COVID-19 might be at an increased risk of having more severe illness. “However, multiple studies have now shown that severe COVID-19 is caused by the development of a hyper-inflammatory state, characterized by dysregulation of the immune system and cytokine storm: the uncontrolled, excessive release of pro-inflammatory Th1-associated cytokines and chemokines, including interferon-γ, IL-1β, IL- 6, TNF-α, monocyte chemoattractant protein-1 (MCP-1), and CXCL10.”

The researchers also observed significantly higher levels of IL-6—associated with poorer outcomes in patients with COVID-19—in IS-NAD compared with IS-AD patients and NIS-NAD patients.

Consistent with this finding, IS-NAD patients were more likely to be prescribed tocilizumab than other patients.

The researchers noted that they did not find any significant differences in any of the other measured cytokines between the groups.


Monreal E, de la Manza S, Fernández-Velasco J, et al. The impact of immunosuppression and autoimmune disease on severe outcomes in patients with hospitalized with COVID-19. J Clin Immunol. Published online November 24, 2020. doi:10.1007/s10875-020-00927-y.