Response to: 'Correspondence on 'Systemic sclerosis and the COVID-19 pandemic: World Scleroderma Foundation preliminary advice for patient management'' by Snarskaya and Vasileva.

We read with great interest the response from Snarskaya and Vasileva.1 A second wave of SARS-CoV-2 infection is now a global reality2: since the publication of the World Scleroderma Foundation preliminary advice on the management on systemic sclerosis (SSc) patients during the first COVID-19 pandemic,3 growing evidence has accumulated on COVID-19 affected SSc patients.4 Up to 22 June, at the end of the first wave, 25 cases of SSc-COVID-19 were published in the literature, most of them undergoing immunosuppressant treatment with corticosteroids (CCS), conventional synthetic disease modifying antirheumatic drugs (csDMARDs) (methotrexate or mycophenolate mofetil) or biological DMARD (bDMARDs) (rituximab or tocilizumab) and with a variable outcome.4 This heterogeneity was a limitation in understanding the possible influence of ongoing immunosuppression and the effect of administered treatments. A recent meta-analysis, including 62 studies with more than 300 000 patients with autoimmune diseases, concluded that bDMARD monotherapy was a protective factor for COVID-19-related hospitalisation and death, in particular with antitumour necrosis factor alpha, while the use of CCS, conventional-synthetic DMARDS (csDMARD) and csDMARDs/bDMARD combination exposed the patients to a higher risk.5 A focused analysis on SSc population has described more SSc-COVID-19 cases: 1/64 patients in Crisafulli et al ,6 1/168 patients in Bellan et al 7 and 2/526 patients in Del Papa et al ,8 …