COVID-19 / SARS-CoV-2 / Coronavirus and Rheumatic disease 4.53/5 (133)

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COVID-19 corona virus can cause complications in rheumatic disease. Photo Credit: US Army

Definition corona (COVID) infection

Coronavirus / coronavirus is a group of different viruses that have a crown-like form (corona). Most types of coronavirus cause colds, although another virus, rhinovirus, is the most common cause of colds. The coronavirus has also previously led to epidemics with serious infections in the form of SARS (Severe Acute Respiratory Syndrome in 2002-2003) and MERS (Middle East Respiratory Syndome, 2012). In December 2019, a new epidemic began from the city Wuhan in China with the virus COVID-2. The virus causes the coronavirus disease which is called COVID-19 and which caused an epidemic in Norway and the rest of the world (pandemic). Vaccines and experienced COVID-19 infections also lead to milder courses of new virus variants.

Infection with the virus begins with its penetration into a cell, such as the lungs. The virus uses the cell to multiply, and it causes the cell to die. Cell death releases neurotransmitters that call for immune cells (monocytes, macrophages and T cells). Normally, the virus should then be neutralized and removed. In someone with COVID-19 disease, this immune response shoots sharply above the target so that this inflammatory process in itself becomes dangerous. It is possible that genetic / hereditary mechanisms (the ACE2 gene and the TLR7 gene) are responsible for some becoming much sicker than others.

COVID-19 and Rheumatic Disease

Infection with COVID-19 can cause temporary muscle pain, but otherwise does not cause significant rheumatic symptoms. People with a weakened immune system may be more prone to complications and a serious course.

Rheumatic diseases, such as arthritis (rheumatoid arthritis), psoriatic arthritis, systemic lupus (SLE), and systemic sclerosis, generally do not appear to increase the risk of COVID infection, related hospitalization, need for ventilator treatment/breathing assistance, or death (reference based on more than 1,1 .2022 million Americans; Mease EULAR 0247, OPXNUMX). Well controlled Rheumatoid arthritis (arthritis) or Systemic lupus (SLE) and without the use of prednisolone or similar corticosteroids are unlikely to have a greater risk of severe COVID-19 prognosis than others of a similar age (reference: D'Silva KM, 2021; Fernandez-Ruiz R, 2021).

However, the use of immunosuppressive treatment against rheumatic disease can increase the risk of serious lung complications and death. It is shown for that biological medicine rituximab and for JAK inhibitors (reference: Sparks JA, 2021). Also high doses Prednisone may increase the risk of COVID-19 infection. Biological TNF inhibitors (a widely used group of biological drugs) do not significantly increase the risk (reference: Gianfrancesco M, 2020). Researchers therefore point out the importance of the rheumatic disease being under control with good drugs, but preferably without high doses of prednisolone (reference: Stranfeld A, 2021).

Among people with rheumatic disease, the risk of a severe course of COVID-19 infection is related to the same factors as for the rest of the population. This applies to old age, men, additional lung, heart and kidney diseases, diabetes, obesity and the unvaccinated (reference: Hasseli R, 2021).

After epidemics with other coronaviruses, data indicate the risk of getting Rheumatoid arthritis (arthritis) increases (9,2% increase) (ref Joo YB, 2019), but recent data from the COVID-19 epidemic do not indicate an increased incidence of arthritis.

Some systemic connective tissue disorders, most often Systemic lupus (SLE) treated with hydroxychloroquine / hydroxychloroquine (Plaquenil). This drug has been tested to prevent coronavirus and COVID-19 disease. Results show that Plaquenil has no effect (Boulware DR, 2020).

MIS-C (multisystem inflammatory syndrome in children)

Among children infected with COVID-19, MIS-C (multisystem inflammatory syndrome in children) is a rare complication (Hu Y, 2021). It is characterized by high fever and signs of disease in many organs, as well as red, inflamed eyes, sore lips, swollen lymph nodes on the neck, rashes and abdominal pain. One has previously thought the condition was part of Kawasaki disease, but is now perceived as a separate disease complication (reference: Diorio C, 2020). Definition of MIS-C: see Henderson LA, 2022. Some differences between corona-/MIS-C infection and Kawasaki disease in children:

SymptomsMIS-CKawasaki disease
Age (median, years)2,59
Continuous feverjaJa
Mucosal inflammationJaJa
Swelling in the hands and feetJaJa
EczemaJaJa
Abdominal pain, diarrhoea, vomitingCommonUnusual
Vasculitis diseasesinJa
Pericarditis, pulmonary congestionJaJa
Coronary artery vasculitis, –aneurysmsinJa
Treatment with immunoglobulins (IVIG), steroids, TNF or IL-1 inhibitorJaYes (IL-6 inhibitor and JAK inhibitors are also used

Symptoms of coronavirus infection

COVID-19 causes symptoms such as a sore throat, fever and dry cough, and some notice reduced senses of smell and taste. The Omicron variant and later mutations can also cause coryza, congestion in the nose and sinuses. COVID-2 the virus has had its own ability to attack the lungs and cause more severe symptoms such as difficulty breathing and pneumonia. If the lungs are attacked, stronger coughing and breathing problems usually begin within a week of the first symptom. It is debated whether the original virus was more serious than Omicron and later variants. There are many indications that strengthened immune defenses from vaccines and past corona virus infections are more decisive for a milder course. Many vaccinated people notice few symptoms, but they can still infect others. Omikron and later BA are the most contagious corona types to date.

Most (80%) develop a flu-like course of illness without the need for special treatment. Symptoms usually resolve within 1-2 weeks. Heavy breathing and/or chest pain is a sign of serious disease development. Such symptoms usually begin 4-7 days after the first symptoms. A doctor should be contacted and hospitalization considered.

Among those who have to be admitted to hospital, some need intensive care, often with a ventilator, which is the necessary breathing aid. This is described as a critical disease phase with a risk of death. Hospitalization and critical illness are most common among older people and with underlying diseases of the lungs and other important organs.

Late effects can consist of long-term sleep difficulties, fatigue and joint pain. It is possible that genetic factors contribute to some people getting long-term symptoms ("long-COVID"). Observations do not indicate that people with rheumatic disease are more susceptible to long-COVID than others.

Coronavirus infection

COVID-19 is transmitted mainly through droplet transmission between humans. Infection can occur when you are in the same room with infected people and especially closer than 1-2 meters. The virus is contagious before the infected person notices symptoms. Thus, infected people can infect others before they even notice the disease.

The virus enters the body through the mucous membranes of the mouth, nose and eyes. Contact infection by direct body contact, infected hands or via common door handles and the like also occurs, because the virus can survive a few days on such surfaces. The virus is transmitted to the mucous membranes via the hands.

Incubation time (time between infection and symptoms) is usually 2-5 days. If symptoms do not occur within 14 days of exposure, one has not been infected.

The risk of infecting others depends on how much virus you have in your body. Usually, someone can easily infect others from a couple of days before the infection is noticed to 4-5 days from the onset of symptoms. Among infected people with a weakened immune system such as during treatment with rituximab, methotrexate and high doses of prednisolone, the virus can last longer in the body. Contagiousness can then persist for a full 10-20 days (reference Center for Disease Control and Prevention (CDC)).

Detection of coronavirus

Assessment of severe symptoms is usually done by a GP, emergency room or private medical centers such as Dr Dropin and others. A call in advance to avoid the risk of spreading the infection in person. Testing for corona virus is usually done with self-test / quick test at home. Test equipment can be purchased at pharmacies and various stores. If the test turns out / is positive, you should stay at home and contact their close contacts. Information can be found on the internet, for example at website for testing in Oslo (reference: Health norge.no).

Rapid tests (antigen tests) can detect viruses/infection from approx. 4-5 days from the time of infection. The tests are effective when the amount of virus in the body has reached a certain level. From the onset of symptoms, it will usually take 4-5 days before most of the virus is defeated by our immune system and the rapid test becomes normal/negative again. PCR tests taken in a hospital show results a little faster, and they stay positive a little longer because they are more sensitive than the rapid tests. With a weakened immune system, such as with strong immunosuppressive drugs, it takes more time. The amount of virus in the body can be measured by the Ct value (cycle threshold). The Ct value is inversely proportional to the amount of virus in the body. A high Ct value means little virus, while a low Ct value means a lot of virus. With a Ct value above 30-33, one is no longer considered to be infectious. However, the results also depend on how much sample material has been obtained.

Pregnant women with COVID-19 infection

The infection usually proceeds in the same way as among non-pregnant women, but a slightly increased risk of hospitalization has been seen. The risk of pneumonia is not increased, and infection between mother and fetus / child is not expected. Nevertheless, COVID-19 disease in the pregnant woman may cause unfavorable stress to the fetus and premature birth in some cases (Mascio DD, 2020).

COVID-19 vaccine

Vaccine against COVID-19 is effective prevention against infection, previously with an effectiveness of 67-95%, but clearly less against omicron and later variants. There is still a risk of infection, even after full vaccination and booster doses, but the infection progresses milder than among unvaccinated people. The effect of the vaccine comes after 2-3 weeks. Booster vaccine has a faster effect. The vaccines are without adjuvants (a type of auxiliary substances) and do not contain products from pigs or mercury. Not least for people with rheumatic disease, vaccination can reduce the risk of serious complications.

In the case of a weakened immune system, such as when using many types of immunosuppressive drugs or advanced age, refresher doses are particularly recommended. These should be taken within approx. 6 months after the last vaccine or the last COVID infection. The municipality of residence must facilitate the vaccination (reference: National Institute of Public Health 14.12.21). Work is being done on a vaccine specifically against omicrons. It will probably be ready during autumn 2022.

Two vaccines, BioNTech / Pfizer (Comirnaty) and the Moderna vaccine (Spikevax), contain RNA (RNA vaccines) which are the recipe for part of the virus surface. The BioNTech / Pfizer vaccine is stored at -70 degrees, the Moderna vaccine in a standard freezer. The Moderna vaccine generally has a slightly better vaccine effect than the Pfizer vaccine, but side effects are more common.

Novavax (Nuvaxovid) is a protein-based corona vaccine that is based on a more traditional vaccine technology than the mRNA vaccines. The vaccine can be given as a substitute for RNA vaccines where it is desired. However, data for the use of Nuvaxovid in severely immunocompromised individuals are still lacking (National Institute of Public Health 16.02.2022). When using immunosuppressive drugs, one should therefore generally be restrained.

The AstraZeneca vaccine (Vaxzervia) vaccine that was used in Norway to begin with Janssen / Johnson & Johnson and the Russian Sputnik which is not used here either, has a different structure. These contain a harmless cold virus that transports the active part of the vaccine into our cells, so that the vaccine works in the body (vector vaccine). The transport virus does not multiply and dies quickly. Like the RNA vaccines, the AstraZeneca, Janssen / Johnson & Johnson and Sputnik vaccines are considered "dead vaccines" and can be given to people with weakened immune systems. The risk of side effects meant that the AstraZeneca vaccine was taken out of use in Norway in March 2021.

Efficacy of the vaccines

People who use immunosuppressive drugs may have a reduced vaccine effect. This applies to many Systemic connective tissue diseases:, Vasculitis and severe joint disease. Drugs that may reduce the vaccine effect are Prednisone in high doses (over 10-30 mg daily over time), methotrexate and similar disease-suppressing drugs, as well biological drugs such as rituximab. A list that includes several of the medications can be accessed via Norwegian Rheumatological Association.

NSAIDs (Ibux, Voltaren and others), paracetamol and other painkillers do not affect the vaccine effect.

It is not routine, but you can measure the vaccine effect in a blood test. SARS-CoV-2 spike antibody shows whether the vaccine has been effective. SARS-CoV-2 nucleoprotein antibody does not show up in vaccinated people, but detects previous infection. These antibody tests are effective weeks after the vaccine or infection and are different from the SARS-CoV-2 RNA (PCR) test which detects the current infection.

People on some types of immunosuppressive therapy for rheumatic diseases will especially need vaccine booster doses regularly to achieve the best possible vaccine effect / immunity (Public Health Institute, 2022). The drugs include most disease-suppressing drugs used against inflammatory rheumatic diseases. For users of Prednisone applies to doses of more than 20mg / day over more than one month which are relatively high doses. Plaquenil (hydroxychlorokine) which is mostly used in systemic lupus (SLE), reduces the immune system relatively little and is not on the list.

The National Institute of Public Health recommends that pregnant women in the 2nd and 3rd trimesters and breastfeeding be vaccinated. There is still a lack of experience with COVID vaccine in pregnant women in the first trimester (first 12 weeks of pregnancy), but with a high risk of infection, vaccination is also relevant early in pregnancy (National Institute of Public Health 10.02.22).

Common vaccine side effects

Common vaccine side effects include pain at the injection site and in the arm for a few days. Headaches, exhaustion, nausea, chills, night sweats, fever and pain in the body are also not rare. The symptoms usually last a couple of days. If signs of side effects increase after 2-3 days from the vaccination, a medical examination is appropriate. Rare side effects are inflammation of the heart muscle (myocarditis) or inflammation of the pericardium (pericarditis). The course of these complications is usually mild and passes after a few days. In rare cases, COVID-19 infection may exacerbate rheumatic disease. Disease exacerbation after vaccination has also been seen, but very rarely.

If you have had a COVID-19 infection, you are usually quite well protected for up to approx. 6 months. If you are nevertheless going to take the vaccine earlier, you should wait at least 3 weeks before the vaccination.

  • All COVID-19 vaccines in Norway (as of October 2022) are "dead vaccines" and are safe for rheumatic disease and antirheumatic treatment.
  • The risk of the vaccine triggering a relapse of rheumatic disease or worsening after vaccination is small.
  • Disease-suppressing treatment for rheumatic disease is usually continued during vaccination, but intake of methotrexate and JAK inhibitors can be delayed 1-2 weeks and rituximab 2-4 weeks after vaccination to ensure the best vaccine effect. Even high doses of prednisolone (above 15 mg / day) may reduce the vaccine effect, but prednisolone should not usually be stopped. In some cases with severe rheumatic disease, one will continue all drug treatment despite the vaccination, because the disease can otherwise cause severe relapse.

Literature: Park KJ, March 25, 2021; ACR Recommendations March 4, 2021

Please read in general about vaccines for rheumatic disease in a separate chapter

Please read more about COVID-19 vaccines on the National Institute of Public Health's information pages

Prevention and treatment of infection with coronavirus

Avoid becoming infected by not traveling to areas where infection must be expected or large crowds gather. Distance between people is important. Frequent and thorough hand washing with soap and good general hygiene is recommended. Antibac and other hand sanitizer, common door handles and the like can also be used. Infected people should wear face masks so as not to spread the infection. Mouthpieces can also protect against infection.

Preventive measures are particularly important for people with a weakened immune system. People who use immunosuppressive drugs and do not have symptoms of infection should still continue with their usual treatment during an epidemic to prevent worsening of severe rheumatic disease. If signs of infection with fever and other flu symptoms should occur, a 1-2 week treatment break with the immunosuppressive treatment may be appropriate, or until the infection is over. However, this assumes that one is not completely dependent on continuous treatment. Everyone should seek advice from their doctor if they have symptoms of the viral disease. Prednisolone and other cortisone preparations should not be stopped abruptly.

  • Antibiotics (against bacteria) do not work against viruses.
  • If the lungs are attacked, oxygen and respiratory assistance (including a respirator) in a hospital can be life-saving until the body has fought the infection.
  • In hospitals, various drugs are used in severe COVID-19 cases. These include remdesvir against viruses and Xevudy (sotrovimab) which unfortunately has an uncertain effect on the most common types of virus in the autumn of 2022. To dampen the immune system's overreaction, corticosteroids, baricitinib, anakinra or tocilizumab are used in some cases.

Paxlovid tablets is used to reduce the course of life-threatening illnesses and admission to hospital. The medication consists of two drugs against viruses (nirmatrelvir and ritonavir). Limited access to the drug and the need for other drugs that should not be used at the same time limit its use. Seniors over 80 years of age are the main target group. In people aged 50-80, there are other risk factors that determine the need for the drug. It is the doctor who assesses whether the overall state of health warrants the use of Paxlovid. For people with rheumatic disease, risk factors for severe COVID-19 infection and the need for Paxlovid may be severe lung or heart disease, chronic kidney failure or immunosuppressive treatment with rituximab in the last 12 months. For people under the age of 50, Paxlovid is only applicable in special cases. Treatment should start within 5 days of the first symptom of infection and the duration of treatment is also 5 days.

One must be aware that Paxlovid cannot be used by everyone. It can be problematic or not recommended to use together with a number of other medicines and natural preparations. In the case of rheumatic diseases, these include medicines for severe pain (morphine-like preparations), some blood-thinning medicines (does not apply to acetylsalicylic acid/Albyl-E/ASA), the blood pressure medicines amlodipine, diltiazem and nifedipine, medicines for pulmonary hypertension, cholesterol-lowering drugs (statins), colchicine and low metabolism (Levaxin). The effect and side effects of prednisolone increase. Some of the drugs are absolutely necessary to take regularly, so Paxlovid cannot then be used. For other medicines and diagnoses, the doctor may recommend a break with or adjusted dose while Paxlovid is being used.

General information is published from Directorate of health. Closer advice intended for healthcare personnel is out for consultation. Paxlovid must be prescribed by a doctor and then on a "blue" prescription (§4, infectious diseases).

Prognosis for COVID infection

Flu symptoms (sore throat, lethargy, fever and dry cough without much mucus) usually develop with a good prognosis. With COVID-19 infection, a small proportion of those infected get severe pneumonia, and lung failure that can be fatal. Most vulnerable are people with known lung disease, diabetes, heart disease, significant obesity, high blood pressure or a weakened immune system (for example, due to immunosuppressive drugs for rheumatic disease, others Autoimmune diseases or cancer). Age over 65 is also a risk factor. Vaccines, especially with multiple doses, are effective for at least 6 months against serious disease, also among people with rheumatic disease. Infection with a virus variant or corresponding vaccine does not necessarily protect against being infected with another variant, but a milder course is expected.

Duration of quarantine

In Norway, there is no longer a general requirement for quarantine after infection. With signs of illness, most people will choose to stay at home, such as with the flu. Infectious persons should in any case take care so that vulnerable persons who have weakened immune systems, old age or other serious illness are not infected (Helsenorge, 7 September 2022). Literature: helsenorge.no

Literature and Links



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