Does lupus or arthritis affect your prognosis if you get COVID-19?

Soon after the coronavirus pandemic began, we learned that older adults and people with certain chronic conditions, such as high blood pressure or diabetes, are at increased risk for severe COVID-19. One condition on that list is an immunocompromised state (a weakened immune system). This can be due to a number of conditions, including having had an organ transplant, having HIV, or taking medications that suppress the immune system.

If you have an autoimmune condition such as rheumatoid arthritis or lupus (also called systemic lupus erythematosus), you may wonder how this affects your risk. It’s thought that these conditions occur because the immune system misfires and attacks organs in the body. And many people with these disorders are treated with medications that suppress the immune system.

Two newly published studies examine this. While the results are not definitive, they do provide some reassurance. Most people recovered from COVID-19, and most of their prior treatments did not seem to worsen their infections.

Lupus and COVID-19

In the first study, researchers enrolled 226 people with lupus. After comparing those who had COVID-19 with those who did not, they found that

• nearly 60% of those with COVID-19 and lupus became sick enough to be hospitalized, and 10% were admitted to the intensive care unit.
• about 10% died.
• risk factors for hospitalization were similar to those reported in people outside of this study who did not have lupus. For example, race (more hospital admissions among those who were Hispanic or nonwhite), other chronic diseases (including kidney failure, lung disease, and hypertension), and being overweight or obese were more common among those needing hospital admission.
• steroid treatment for lupus was nearly two times higher among hospitalized patients (54%) compared with those who were not hospitalized (29%). However, this difference was not statistically significant.
• treatment with other immune-suppressing medications taken for lupus (such as azathioprine or mycophenolate) was similar in both groups.

Inflammatory arthritis and COVID-19

The second study included 103 people with inflammatory arthritis (which includes rheumatoid arthritis and related conditions) who were also diagnosed with COVID-19. Some were hospitalized with severe disease, while others were treated as outpatients. Here’s what the study found.

• 26% of study subjects were hospitalized.
• About 4% died.
• Risk factors for hospital admission included being 65 or older, high blood pressure, and lung disease.
• Steroid treatment for inflammatory arthritis was more common among those hospitalized (37%) than those treated as outpatients (about 4%).
• Biologic therapy (such as etanercept or infliximab) did not appear to increase the risk of severe COVID-19. One other type of treatment — JAK inhibitors, which include tofacitinib (Xeljanz) — was more common among those requiring hospital admission. However, few patients were taking this medication.

Why these studies aren’t the last word

These studies only included patients with COVID-19 and either SLE or inflammatory arthritis. It wasn’t possible to rigorously compare the study participants to people without lupus or arthritis. Also, these studies did not include large numbers of people with lupus or arthritis who tested positive for the virus, yet did not have symptoms of COVID-19 (asymptomatic infection). Nor did they confirm the diagnosis of COVID-19 in every suspected case. So, while this research offers some new information, the true impact of lupus or arthritis on people who develop COVID-19 hasn’t yet been determined.

Finally, the lupus study was small: only 41 subjects had confirmed COVID-19. Although the findings on steroid treatment weren’t statistically significant, that might not have been true if the differences observed persisted in a larger study.

The bottom line

Public health experts often include people with autoimmune disease on the list of those who are more likely to have a bad outcome if they develop COVID-19. The relatively high rate of hospital admission for lupus patients with COVID-19 confirms an increased risk for severe disease. Other standard risk factors (such as high blood pressure or lung disease) apply, but steroid therapy may increase risk even further. Other studies have come to similar conclusions (see here and here).

There was some good news to emphasize in these trials: the survival rate among patients with lupus or inflammatory arthritis who develop COVID-19 was relatively high. Also, biologic therapy did not appear to worsen prognosis for the arthritis patients. And other immune suppressants did not worsen prognosis for those with lupus. And, the hospitalization rate for COVID-19 among patients with inflammatory arthritis was similar to what has been reported for people without arthritis.

These findings add to what we are learning about COVID-19. Clearly, we need to learn more. For example, is there a dose of steroids to treat chronic illness that is so low that it does not increase the risk of a worse prognosis with COVID-19? Do certain medications (such as biologics) actually reduce the risk of severe COVID-19? Until we do know more, it remains particularly important for people with lupus and inflammatory arthritis — especially those taking steroids — to be especially vigilant about measures to avoid COVID-19.

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