Effects of immunosuppressive drugs on COVID‐19 severity in patients with autoimmune hepatitis

Abstract

Background: We investigated associations between baseline use of immunosuppressive drugs and severity of Coronavirus Disease 2019 (COVID-19) in autoimmune hepatitis (AIH). Patients and methods: Data of AIH patients with laboratory confirmed COVID-19 were retrospectively collected from 15 countries. The outcomes of AIH patients who were on immunosuppression at the time of COVID-19 were compared to patients who were not on AIH medication. The clinical courses of COVID-19 were classified as (i)-no hospitalization, (ii)-hospitalization without oxygen supplementation, (iii)hospitalization with oxygen supplementation by nasal cannula or mask, (iv)-intensive care unit (ICU) admission with non-invasive mechanical ventilation, (v)-ICU admission with invasive mechanical ventilation or (vi)-death and analysed using ordinal logistic regression. Results: We included 254 AIH patients (79.5%, female) with a median age of 50 (range, 17-85) years. At the onset of COVID-19, 234 patients (92.1%) were on treatment with glucocorticoids (n = 156), thiopurines (n = 151), mycophenolate mofetil (n = 22) or tacrolimus (n = 16), alone or in combinations. Overall, 94 (37%) patients were hospitalized and 18 (7.1%) patients died. Use of systemic glucocorticoids (adjusted odds ratio [aOR] 4.73, 95% CI 1.12-25.89) and thiopurines (aOR 4.78, 95% CI 1.33-23.50) for AIH was associated with worse COVID-19 severity, after adjusting for age-sex, comorbidities and presence of cirrhosis. Baseline treatment with mycophenolate mofetil (aOR 3.56, 95% CI 0.76-20.56) and tacrolimus (aOR 4.09, 95% CI 0.69-27.00) were also associated with more severe COVID-19 courses in a smaller subset of treated patients. Conclusion: Baseline treatment with systemic glucocorticoids or thiopurines prior to the onset of COVID-19 was significantly associated with COVID-19 severity in patients with AIH.

COVID-19 and liver disease

“…Similar findings were reported in a multicentre cohort of 110 patients with AIH who also had comparable outcomes to other liver disease types despite high rates of immunosuppression 84. However, a larger retrospective study from the same group, including 254 patients with AIH with COVID-19, did show that baseline treatment with systemic glucocorticoids (median dose: 5 mg/day) or azathioprine (median dose: 75 mg/day) was associated with COVID-19 severity compared with no treatment 85. Data for patients with PBC and primary sclerosing cholangitis (PSC) are limited, although one nationwide study in Spain did observe a higher cumulative incidence of hospitalisation and mortality in patients with PBC compared with the general population although interpretations are limited by the lack of adjustment for comorbidities 86…”

Impact of COVID-19 on the liver and on the care of patients with chronic liver disease, hepatobiliary cancer, and liver transplantation: An updated EASL position paper

“…Similar findings were concurrently reported in a multi-center cohort of 110 AIH patients who also had comparable outcomes to other liver disease types [ 87 ]. However, a larger retrospective study from the same group including 254 AIH patients with COVID-19 did indicate that baseline treatment with systemic glucocorticoids (median dose 5 mg/day) or azathioprine (median dose 75 mg/day) were associated with more severe COVID-19 [ 88 ] after adjusting for age, sex, comorbidities, and presence of cirrhosis. Data for patients with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are limited.…”

Clinical update on risks and efficacy of anti-SARS-CoV-2 vaccines in patients with autoimmune hepatitis and summary of reports on post-vaccination liver injury

“…Therefore, the European Association for the Study of the Liver (EASL) has recommended vaccination against SARS-CoV-2 for all patients with CLD [3] . Although contrasting data have been published, patients with AIH with or without cirrhosis under immunosuppressive therapy represent an at-risk category of developing severe COVID-19 when infected [ 4 , 5 ]. Therefore, based on the data available, the benefit of anti-SARS-CoV-2 vaccination outweighs the potential risk for disease exacerbation in AIH.…”