Tiago Torres, MD, PhD
Department of Dermatology, Centro Hospitalar Universitário do Porto
PUBLICATIONOpenSAFELY: factors associated with COVID-19 death in 17 million patients. Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. Nature. 2020 Jul 8. doi: 10.1038/s41586-020-2521-4.
The outbreak of COVID-19 had affected the management of several cutaneous immune-mediated diseases, including psoriasis.
When compared to the general population, most of the published data has shown no increased risk of hospitalization in intensive care and death from COVID-19 in psoriasis patients receiving conventional and biological treatment. Moreover, some biologic treatment may even protect against severe manifestations of COVID-19.
However, several comorbidities known to be associated with psoriasis, such as cardiovascular disease, hypertension, diabetes or obesity, have been identified as risk factors for severe COVID-19 outcomes. Thus, the risk appears to be derived mainly from the patients’ characteristics, rather than from their pharmacological treatment. Therefore, it is extremely important to understand who is at most risk for serious outcomes from COVID-19 infection.
In this study, Elizabeth J. Williamson and colleagues present the first results of the largest cohort study conducted by any country to-date. Williamson et al, aimed to identify, quantify, and explore risk factors for COVID-19-related death, using the OpenSAFELY secure health analytics platform, which covers 40% of all patients in England.
A total of 17,278,392 adults were pseudonymously linked to 10,926 deaths due to COVID-19. Increased risk of death from COVID-19 was associated with being male, older age and several other medical conditions, including cardiovascular disease, diabetes, respiratory disease (including severe asthma), obesity, history of hematological malignancy or other cancer, kidney, liver, neurological and autoimmune conditions (grouped as rheumatoid arthritis, lupus or psoriasis).
Also, non-white ethnicity and deprivation were associated with higher risk of death: all non-white ethnic groups had a substantially higher risk than those with white ethnicity, even after adjustment for other factors, being only partially attributable to co-morbidities, deprivation or other risk factors; deprivation-associated excess risk was also only explained in a small part by pre-existing diseases or clinical risk factors, suggesting the role of other social factors.
The findings largely concurred with other data previously published. However, the OpenSAFELY platform allows higher precision and statistical power due to the sample size and access to more detailed patient data than the one recorded on admission. Patient records are continually being updated and added as well.
From the point of view of our specialty, the results of the association between autoimmune conditions (including psoriasis) and a higher risk of death related to COVID-19, which until now had not been demonstrated, are particularly interesting. In fact, a recent published meta-analysis showed no significant association between autoimmune disease and severe disease and mortality from COVID-19. Nevertheless, in this study, an age-sex adjusted and fully adjusted COVID-19-related death HR (95% CI) of 1.30 (1.21-1.38) and 1.19 (1.11-1.27) respectively, was shown for autoimmune conditions (grouped as rheumatoid arthritis, lupus or psoriasis).
It is difficult to state if psoriasis per se, is indeed associated with higher COVID-19-related death, due to this group analysis. Rheumatoid arthritis and lupus clearly differ from psoriasis, immunologically and in the therapies used, requiring further data analysis and studies. Moreover, these results clearly confirm previous data, that many psoriasis-associated comorbidities increase the risk of severe COVID-19 outcomes, including death, demanding our attention in particular.
In summary, considering all the available data, our clinical decisions in psoriasis should consider the risk/benefit on a case-by-case basis, depending on the individual risk of COVID-19.