COVID-19, Coronavirus and Rheumatic Disease 4.52/5 (130)

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

Definition

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 causes 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. A study of 600 patients with various rheumatic diseases from 40 countries showed that Prednisolone 10 mg / day or more increased the risk of hospitalization in case of COVID-19 infection. Treatment with TNF inhibitors (a group of biological drugs) did not show an increased risk (reference: Gianfrancesco M, 2020).

Among people with rheumatic disease, the risk of dying from COVID-19 infection is related to the same factors as for the general population. This applies to old age, men and additional diseases of the lungs and heart. 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 for prevention against 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

COVID-19 causes symptoms such as sore throat, fever and dry cough and some notice decreased senses of smell and taste. Nasal congestion is not typical. People rarely sneeze, unlike the common cold. 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 variant of the virus more often gives a milder and more cold-like course. Many vaccinated people notice little or no symptoms, but they still infect others. Omikron is the most contagious corona variant to date.

Course of disease

Most (approx. 80%) have a fairly mild course of the disease 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, 15-35% 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.

Contamination

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 2 weeks of exposure, one has not been infected.

Detection of coronavirus

Assessment of symptoms that can be serious is usually done by a GP, emergency room, a corona center or private medical centers such as Dr Dropin and others. If you have been exposed to an infection, you must call in advance to avoid the risk of spreading the infection when attending. Tests for corona virus are performed at separate centers in each municipality. Information can be found on the internet, for example at website for testing in Oslo. One can also test oneself at home with quick tests. These can be bought at pharmacies and various shops. If the test turns out to be positive, you must report it to the municipality's corona center.

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 less against the omicron variant. It still carries a risk of infection, even after full vaccination with two or three 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 an effect already after a few days. 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 virus variant omicron, which was discovered in the autumn of 2021 in South Africa, 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.

A third dose of vaccine protects better than two doses. In case of weakened immune system, such as with the use of many types of immunosuppressive drugs, three vaccine doses are considered the basis for the primary vaccination. Refreshment dose will then be a fourth dose. This can be set 3 months or more after the third 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 summer 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.

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.

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 indicates whether the vaccine has been effective. 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.

Many people with immunosuppressive treatment, like older people, will generally have a greater need for a third vaccine dose to achieve vaccine effect / immunity. The National Institute of Public Health has drawn up guidelines (14.09.21) for which drugs indicate that a third vaccine dose is appropriate. These include most disease-suppressing drugs used to treat 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. From three months after the third dose, a fourth refresher dose may be given as a reference: National Institute of Public Health 14.12.21). It is each municipality that facilitates the vaccination.

The National Institute of Public Health recommends that pregnant women in the 2nd and 3rd trimesters be vaccinated. Also breastfeeding vaccine is recommended. 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 01.12.21).

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 good, so the symptoms go away after a few days.

If you have had a COVID-19 infection, you should wait approx. 3 months of vaccination.

  • All COVID-19 vaccines in Norway (as of January 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 low.
  • 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. Also, high doses of prednisolone (above 15mg / 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

Treatment

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.
  • 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

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

Literature: helsenorge.no pr 05.05 2021

Literature and Links



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