Paper Information

Corticosteroids are associated with greater risk of COVID-19 hospitalisation and death, especially among unvaccinated individuals. Concurrent use of DMARDs and TNFis with corticosteroids confers greater risk.

There were 10 109 596 eligible patients enrolled during the risk period, each with at least 365 days of continuous enrolment prior to 1 July 2021.

Systemic corticosteroids, disease-modifying antirheumatic drugs (DMARDs), tumour necrosis factor-alpha inhibitors (TNFis) and other immunosuppressive drug categories.

This is a retrospective cohort study using a deidentified insurance claims database from 1 July 2020 to 30 June 30, 2022, with the risk period starting on 1 July 2021. Impact of corticosteroid exposures and concurrent use of other immunosuppressants was assessed with attributable risk analysis and Cox regression that included COVID-19 vaccination status and time-updated dichotomous immunosuppressive medication exposures.

To assess the association between corticosteroid dose/duration and concurrent immunosuppressant use on COVID-19 hospitalisation and death in the era of COVID-19 vaccinations.

Incidence rate ratios and hazard ratios for COVID-19 hospitalisation and death.

Immunocompromised status is a risk factor for severe SARS-CoV-2 infection. Little is known about how systemic corticosteroid dose and concurrent use of immunosuppressants are associated with COVID-19 outcomes.

Corticosteroids were prescribed to 1 379 049 (13.6%) of 10 109 596 individuals. After adjustment, corticosteroids were associated with an increased risk of COVID-19 hospitalisation (HR: 5.40; 95% CI 5.27 to 5.53; p<0.0001) and death (HR: 5.90; 95% CI 5.59 to 6.22; p<0.0001). Among individuals exposed to corticosteroids without a record of COVID-19 vaccination, risks for COVID-19 hospitalisation and death were increased by 3- and 14.5-fold. The population attributable risk of corticosteroid use for COVID-19 hospitalisations was 13.9% (95% CI 13.5 to 14.3%). There was a significantly increased risk of COVID-19 hospitalisation associated with the use of corticosteroids plus DMARDs (HR: 1.55; 95% CI 1.42 to 1.70; p<0.0001) or plus TNFis (HR: 1.60; 95% CI 1.15 to 2.22; p=0.005).