COVID-19, Coronavirus and Rheumatic Disease 4.52/5 (132)

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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. Coronavirus in the past also caused 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).

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 transient 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. This may apply when using immunosuppressive therapy such as Biological drugs, Methotrexate, Salazopyrin, Imurel, CellCept and more and high doses Prednisone against serious rheumatic diseases. Prednisolone 10 mg / day or more increases the risk of hospitalization in case of COVID-19 infection. Treatment with TNF inhibitors (a group of biological drugs) does not significantly increase the risk (reference: Gianfrancesco M, 2020).

Among people with rheumatic disease, the risk of severe COVID-19 infection is related to the same factors as for the general population. This applies to old age, men, additional diseases of the lungs and heart and non-vaccinated. Apart from these, high rheumatic disease activity and high doses of prednisolone are important. Researchers therefore point out the importance of the rheumatic disease being under control with good drugs, preferably without high doses of prednisolone (reference: Stranfeld A, 2021).

People with well controlled Rheumatoid arthritis (arthritis) or Systemic lupus (SLE) and those who do not use prednisolone or similar corticosteroids are unlikely to be at greater risk of severe COVID-19 prognosis than others of similar age (reference: D'Silva KM, 2021; Fernandez-Ruiz R, 2021).

Previous data suggest that Rheumatoid arthritis (arthritis) begins more frequently (9,2% increase) after epidemics with other coronaviruses (reference) Joo YB, 2019), but data do not indicate this for COVID-19.

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).

Among children infected with COVID-19, MIS-C (multisystem inflammatory syndrome in children) is a rare complication. It is characterized by high fever and signs of illness in many organs, as well as red, inflamed eyes, sore lips, swollen lymph nodes in the neck, rash and abdominal pain. One has previously thought the condition was a part of Kawasaki disease, but is now perceived as a separate disease complication (reference: Diorio C, 2020).

Symptoms of coronavirus infection

COVID-19 causes symptoms such as sore throat, fever and dry cough and some notice decreased senses of smell and taste. The Omicron variant can also cause runny nose, nasal congestion 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, severe coughing and breathing problems usually begin within a week of the first symptom. The Omicron variants of the virus more often give a milder and more cold-like course. Many vaccinated people do not notice any symptoms, but they can still infect others. Omikron is the most contagious corona variant to date. Omicron BA2 was most common in winter and spring 2022, while omicron BA5 will dominate throughout the summer and autumn.

Disease course in coronary heart disease

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

Among those who need to be hospitalized, some need intensive care, often with a respirator that requires breathing assistance. This is described as a critical disease phase with a risk of death. Hospitalization and critical illness are most common among the elderly and in underlying diseases of the lungs and other important organs.

Late effects may include prolonged difficulty sleeping, fatigue and joint pain.

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 4-5 days. If symptoms do not occur within 10-14 days of exposure, one has not been infected.

The risk of infecting others depends on how much virus one has in the body. Usually, one can easily infect others from a few days before the infection is noticed to 4-5 days from the onset of symptoms. Among infected individuals with a weakened immune system, such as treatment with rituximab, methotrexate and high doses of prednisolone, the virus may last longer in the body. Infectiousness 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

Rapid tests (antigen tests) can detect viruses / infections from approx. 4-5 days from time of infection. The tests take effect 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 has been defeated by our immune system and the rapid test becomes normal / negative again. With a weakened immune system, it takes more time. PCR tests taken at test centers turn out a little faster and they stay positive a little longer because they are more sensitive than the quick tests.

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, usually with an effectiveness of 67-95%, but clearly less against the omicron variant. It still carries a risk of infection, even after full vaccination and refresher doses, but the infection then proceeds more mildly than among the unvaccinated. The effect of the vaccine comes after 2-3 weeks. Refreshment vaccine has a faster effect. The vaccines are without adjuvant (a type of excipient) and do not contain products from pigs or mercury. Not least for people with rheumatic disease, vaccination will reduce the risk of serious complications.

The omicron virus variant, which was first discovered in South Africa in the autumn of 2021, is also causing some of the epidemic in Norway. This virus variant is milder but more contagious and the vaccines are less effective. The unvaccinated are much more prone to serious illness and complications of this variant as well.

In case of weakened immune system, such as with the use of many types of immunosuppressive drugs, refreshing doses are recommended. These can be given 3 months or more after the last dose. The municipality of residence shall facilitate the vaccination (reference: National Institute of Public Health 14.12.21). A vaccine is being worked on specifically for omicron, but it will not be ready until the autumn of 2022 at the earliest.

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 coronary vaccine based on a more traditional one
vaccine technology than the mRNA vaccines. The vaccine can be given as a replacement for RNA vaccines where desired. However, data on the use of Nuvaxovid in people with severe immune deficiency 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.

The vaccine effect can be measured in a blood test. SARS-CoV-2 spike antibody shows whether the vaccine has had an effect. SARS-CoV-2 nukeoprotein antibody does not knock out in vaccinated people, but detects previous infection. These antibody tests knock out weeks after vaccination or infection and are distinguished from SARS-CoV-2 RNA (PCR) test which detects current infection. However, the test is not a normal or necessary routine, but is used in special cases.

Some people with immunosuppressive therapy for rheumatic diseases will need vaccine refreshment 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) most commonly 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, fatigue, nausea, chills, night sweats, fever and body aches are also not uncommon. The symptoms usually last a couple of days. If signs of side effects increase after 2-3 days from vaccination, a medical examination may be appropriate. Rare side effects are myocarditis (inflammation of the 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 should wait approx. 3 months of vaccination.

  • All COVID-19 vaccines in Norway (as of June 2022) are "dead vaccines" and are safe for rheumatic disease and anti-rheumatic 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 after coronavirus infection

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 especially important for people with a weakened immune system. People who use immunosuppressive drugs and do not have symptoms of infection should, during an epidemic, continue with their usual treatment to prevent exacerbation of severe rheumatic disease. If signs of infection with fever and other flu symptoms occur, a 1-2 week treatment break with the immunosuppressive treatment may be appropriate. However, this presupposes that one is not completely dependent on continuous treatment. In case of symptoms of the viral disease, each individual should seek the advice of their doctor. Prednisolone and other cortisone preparations should not be discontinued 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.
  • Xevudy (sotrovimab) is an intravenous treatment with a human monoclonal antibody that binds to the spike protein on COVID-19 so that the infection progresses more gently. The drug is usually given in infectious disease wards for immunocompromised patients who have an increased risk of severe COVD-19 disease, such as concomitant severe lung function.
  • A new antiviral tablet is Paxlovid (from Pfizer) which consists of nirmatrelvir and ritonavir will be available in 2022. In case of infection, this will reduce the symptoms in most cases.

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 three or four doses, have a very good effect against serious illness also among people with rheumatic disease.

Infection with a virus variant or similar vaccine does not necessarily protect against becoming 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, 6 April 2022).


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