A survey conducted by a team of US-based scientists has recently demonstrated that patients with systemic autoimmune rheumatic diseases commonly experience augmented disease severity and disrupted treatment regimens of disease-modifying antirheumatic drugs after acute coronavirus disease 2019 (COVID-19) course. In addition, almost 50% of the patients experience prolonged COVID-19-related symptoms, including pain, fatigue, breathlessness, and loss of smell and taste. A preprint version of this study is currently available on the medRxiv* preprint server.
Immunocompromised patients, including those with systemic autoimmune rheumatic diseases, are at higher risk of severe COVID-19, a novel disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In addition to the direct impact of SARS-CoV-2 infection, changes made in the therapeutic regimen of disease-modifying antirheumatic drugs have been shown to influence the management of underlying rheumatic diseases.
Moreover, studies have suggested that some rheumatic disease patients experience prolonged COVID-19 symptoms (long-COVID) and an overall deterioration in the quality of life during the recovery phase. Higher susceptibility to long-COVID could be due to the shared characteristics of acute SARS-CoV-2 infection and rheumatic diseases, such as hyper-inflammation, hyper-coagulation, autoimmune responses, and fibrosis.
In the current study, the scientists have assessed the impact of acute SARS-CoV-2 infection on the clinical course and management of rheumatic diseases during the COVID-19 recovery phase. They have specifically focused on the augmentation of rheumatic disease severity, disruption in antirheumatic therapies, and duration of long-COVID-19 symptoms.
The study was conducted on a total of 174 patients with systemic autoimmune rheumatic diseases who had laboratory-confirmed COVID-19. Among rheumatic diseases, rheumatic arthritis was the most common, followed by systemic lupus erythematosus and psoriatic arthritis. The most commonly observed comorbidities were obesity, hypertension, and asthma.
The participants were contacted for an online survey to collect information on demographics, clinical characteristics of rheumatic diseases before and after COVID-19, comorbidities, intensity and duration of COVID-19 symptoms and disease course, vaccination status, and rheumatic disease-related treatments before and after COVID-19.
The clinical course of acute and post-acute COVID-19
All participants showed an average symptom duration of 14 days. In most participants, the most commonly observed symptoms during acute SARS-CoV-2 infection were fatigue, fever, and headache. About 45% of participants experienced long-lasting symptoms for an average of 46 days.
The participants with prolonged symptoms for more than 28 days had significantly higher numbers of initial symptoms than those without prolonged symptoms. The participants with prolonged symptoms also exhibited higher hospitalization rates and higher requirements of in-hospital oxygen supplementation and high-dose glucocorticoids and remdesivir. The number of initial symptoms and rate of COVID-related hospitalization were identified as potent predictors of long-COVID (prolonged symptom duration).
Disruption of antirheumatic therapies after COVID-19
About 18% of participants received glucocorticoids during the acute phase of COVID-19. A total of 127 participants were prescribed disease-modifying antirheumatic drugs. Of them, about 51% experienced some disruption in therapies, including temporary discontinuation, increased dosing interval, reduced drug dose, and administration of a new drug.
The analysis of treatment regimens in each participant revealed that about 60-77% of them had disrupted regimens. Only two drugs, including hydroxychloroquine and rituximab, were identified to have minimal disruption. Specifically, hydroxychloroquine and rituximab were disrupted in 23% and 46% of participants, respectively. After excluding these two drugs, the analysis revealed that the therapeutic regimens of about 73% of all disease-modifying antirheumatic drugs were disrupted in participants.
Rheumatic disease flare
A significant deterioration in rheumatic disease activity was observed in participants following acute COVID-19 compared to that before disease onset. Specifically, about 41% of participants reported rheumatic disease flare occurring mostly 1 – 4 weeks after COVID-19 diagnosis.
The participants with prolonged symptoms experienced higher pain and fatigue levels than those without long-COVID. In addition, these participants experienced a deterioration in their respiratory quality of life.
The study demonstrates that antirheumatic therapy disruption, disease flares, and long-COVID symptoms are common among patients with systemic autoimmune rheumatic diseases who recently have SARS-CoV-2 infection. Overall, the study highlights the significant negative impact of acute SARS-CoV-2 infection on the long-term management of rheumatic diseases.
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.
DiIorio, M. et al. (2022) "DMARD disruption, disease flare, and prolonged symptom duration after acute COVID-19 among participants with rheumatic disease: A prospective study". medRxiv. doi: 10.1101/2022.02.08.22270696. https://www.medrxiv.org/content/10.1101/2022.02.08.22270696v1