Risk for Adverse COVID-19 Outcomes in Patients With Immune-Mediated Inflammatory Diseases Treated With TNF Inhibitors

doctor speaking to patient in ICU wearing mask
Female doctor in protective suit consoling senior patient. Elderly man with oxygen mask is lying on bed in intensive care unit during COVID-19 crisis. They are in hospital ward.
Researchers sought to assess the risk for COVID-19-related hospitalization or death among patients with immune-mediated inflammatory diseases receiving treatment with tumor necrosis factor inhibitors.

Compared with other commonly prescribed immunomodulatory regimens, treatment with tumor necrosis factor inhibitors (TNFis) was found to decrease the risk for adverse COVID-19 outcomes in patients with immune-mediated inflammatory diseases (IMIDs), according to study findings presented at the American College of Rheumatology (ACR) Convergence 2021, held virtually from November 3 to 10, 2021.

Researchers used data from 3 global COVID-19 registries to assess outcomes of COVID-19-related hospitalization or death associated with TNFi monotherapy among patients with IMIDs. The risk for hospitalization or death also was assessed among patients receiving treatment with other immunomodulatory regimens, including TNFis in combination with AZA/6-mercaptopurine (AZA/6MP), AZA/6MP monotherapy, methotrexate (MTX) monotherapy, and Janus kinase (JAK) inhibitor monotherapy.

Outcomes of COVID-19 and demographic and clinical characteristics were reported among patients with IMIDs with confirmed or suspected SARS-CoV-2 infection. Patients with resolved SARS-CoV-2 infection who were diagnosed with inflammatory arthritis, IBD, or psoriasis on or before February 1, 2021, were included in the current analysis.

The researchers performed individual and pooled analyses of data from 3 global COVID-19 registries, using multilevel multivariable mixed-effect logistic regression; adjustments were made for patients’ demographic and clinical characteristics, comorbidities, and concomitant immunomodulatory medications. In addition, the researchers performed a sensitivity analysis that excluded patients who were diagnosed with SARS-CoV-2 infection on the basis of symptoms alone.

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A total of 6077 patients from 74 countries who were included in the analysis. The mean age of patients was 48.8±16.5 years; 58.6% were women; 35.3% had rheumatoid arthritis; and 25.3% had Crohn disease. In addition, 21.3% of patients were hospitalized due to COVID-19 and 3.1% died.

In the pooled analysis, the researchers found that risk for hospitalization was increased among patients who received treatment with TNFi monotherapy in combination with AZA/6MP (odds ratio [OR], 1.7; 95% CI, 1.2-2.6), AZA/6MP monotherapy (OR, 1.8; 95% CI, 1.3-2.6), MTX monotherapy (OR, 2.0; 95%CI, 1.6-2.6), or JAK inhibitor monotherapy (OR, 1.8; 95% CI, 1.2-2.7) compared with those who received treatment with TNFi monotherapy alone.

Of note, the researchers found that both individual and pooled analyses of data from the 3 global registries showed similar ORs among the included immunomodulatory regimens with regard to risk for hospitalization or death. In addition, similar findings were observed after excluding patients who were diagnosed with SARS-CoV-2 on the basis of symptoms alone.

“These [findings] can help inform treatment decisions for individuals with IMIDs during the [COVID-19] pandemic,” the researchers concluded.

Disclosure: Some authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of disclosures.

I often hear patients asking, “Why am I taking this medication?”  Whether it is a medication prescribed by a primary care physician, specialist, or emergency medicine provider, this question needs to be answered and understood by all patients. Prescription labels for medications taken as-needed typically include the indication for use, but prescriptions for chronic illnesses typically do not. This information is especially important when patients are on multiple medications. The issue comes down to health literacy.

Studies have shown that more than 75% of patients lack understanding about prescription label instructions, and some patients stop taking medications if they don’t know what it is prescribed for.1 This lack of information is a source of frustration for patients, their caretakers/families, and their providers. Many older patients in my practice ask me about their medications. After explaining the indication for each medication, I write the reason for the prescription on the bottle with a marker if they have their medicine with them or I indicate the information on their paperwork. The simple act of writing down the purpose for the medication helps patients understand why the agent is important to their heath and serves as a reminder over time.  

Misunderstanding the “why” may affect patient’s willingness to take needed medications. Medication nonadherence affects quality of life and leads to more than $100 billion in avoidable hospitalizations.2 Not knowing the “why” can lead to chronic illness exacerbations causing multiple office/emergency department visits or hospitalizations as well as increased time spent by office staff and/or pharmacy staff to address patient questions. To help reduce this burden, the Institute of Medicine encourages the standardization of prescription use instructions given that the medication label is a key source of information for patients.3 This practice can save time, confusion, and money for patients, families, providers, pharmacists, hospitals, and insurance companies.

Nurse practitioners (NP) can lead this transformation in their practice. Awareness that patients need information on the purpose of their medications is necessary for change to begin. After discussing this need with patients, colleagues, and support staff, the indication for use of each medication can be written on prescriptions for all patients. This act will serve as a reminder of the “why” and will help patients take control of their health care.

Karen A. Bocchicchio MSN, FNP-C, APN-C, is a practicing clinician as well as lead clinician at a Penn Medicine primary care office in New Jersey. She is a clinical nursing adjunct for nurse practitioner students at Rowan University. She is also pursuing her DNP at Rutgers University.


1. Davis TC, Federman AD, Bass PF 3rd, et al. Improving patient understanding of prescription drug label instructions. J Gen Intern Med. 2009;24(1):57-62. doi:10.1007/s11606-008-0833-4

2. Cutler DM, Everett W. Thinking outside the pillbox–medication adherence as a priority for health care reform. N Engl J Med. 2010;362(17):1553-1555. doi:10.1056/NEJMp1002305

3. Institute of Medicine. Standardizing Medication Labels: Confusing Patients Less: Workshop Summary. The National Academies Press; 2008. https://doi.org/10.17226/12077.


Izadi Z, Brenner E, Mahil S, et al. TNF inhibitors and the risk of adverse COVID-19 outcomes in patients with immune-mediated inflammatory disease: pooled data from three global registries. Presented at: ACR Convergence 2021; November 3-10, 2021. Abstract 0087.

This article originally appeared on Rheumatology Advisor