What does infection with Covid 19 mean specifically for rheumatology patients?
The German Society for Rheumatology developed recommendations for patients with inflammatory rheumatic diseases very early in the pandemic in order to guide patients through the pandemic in the best possible way. These recommendations have been continuously updated since then. In March 2020, the recommendations were based on the experience of experts as well as analogies from available data from the course of other viral infections, then in the course of the pandemic increasingly also on findings of an infection with SARS-CoV-2.
It is important for patients with inflammatory rheumatic diseases that any activation of their rheumatic disease is to be avoided. Indeed, an active rheumatic disease increases the risk of infection – and if the rheumatic disease is then treated with cortisone, this further increases the risk of infection. On the other hand, there are data – apart from cortisone – for only a very few drugs that are used to treat inflammatory rheumatic diseases that indicate a risk to rheumatism patients. These include rituximab, cyclophosphamide and possibly – the data are not clear – mycophenolate. For all other drugs used in the therapy of patients with inflammatory rheumatic diseases, there is no risk of infection and therefore the recommendation of the DGRh is also consequently not to change or even discontinue the anti-inflammatory therapy of the rheumatic disease in the vast majority of patients.
A patient with an inflammatory rheumatic disease is per se no more endangered to suffer a SARS-CoV-2 infection than a person not suffering from rheumatism. Special precautions are therefore not necessary for patients with inflammatory rheumatic diseases – a consistent adherence to the applicable distance and hygiene rules is (as for every human being too…). If a SARS-CoV-2 infection is detected by PCR test, a pause of certain medications for a few days can be considered to see if the infection actually leads to a disease. However, this does not apply to cortisone at a low dosage, which should continue to be taken. If a patient with inflammatory rheumatic disease develops symptoms of COVID-19 disease, the continuous therapy of the rheumatic disease should be interrupted – in consultation with the treating rheumatologists and according to the recommendations of the DGRh. It is also important to note here that any activity of the rheumatic disease represents a risk for the patient and should therefore be avoided at all costs.
A patient with rheumatism develops the same symptoms as a person not suffering from rheumatism. However, if rheumatoid disease has affected internal organs such as the heart or lungs, rheumatoid patients are at serious risk for a more severe course of COVID-19 infection. Therefore, it is important to avoid the risks for SARS-CoV-2 infection as much as possible. Not by special measures, but by a good therapy of the rheumatic disease, the observance of the generally valid hygiene and distance rules and a vaccination against SARS-CoV-2.
What are the findings from the Covid-19 registry?
The COVID-19 registry of the DGRh is an unimaginable treasure for rheumatism patients, as it allows us to collect data on the course of an infection, on risk factors for an infection or a severe COVID-19 disease, but precisely also data on the safety of a rheumatism therapy and thus to advise our patients correctly and not on the basis of assumptions. The registry has helped to ensure that we know the major risk factors (older age, obesity, comorbidities, high disease activity of rheumatic disease). It has also helped save lives, because in the registry we recognized as early as May 2020 that certain therapies had a high risk for severe, sometimes fatal, courses of SARS-CoV-2 infection. This realization has led to the review and often modification of such therapies on a case-by-case basis.
In the registry, we also record vaccination and its consequences for patients with inflammatory rheumatic diseases, and we can rightly say that the risk of activation of rheumatic disease by vaccination is very very low (about 1% of those vaccinated).
What speaks – with regard to rheumatism – for or against covid vaccination?
Vaccination against SARS-CoV-2 is the only way to reduce the risk of infection as well as the risk of a severe course of COVID-19 disease. The vaccines are safe, they are not live vaccines, and the data from observational studies and registries show that they pose no different risk to patients with inflammatory rheumatic disease than to those who do not have rheumatic disease.
While it is true that transient activation of underlying rheumatic disease can occur after SARS-CoV-2 vaccination, as with any vaccination, it is similarly likely to happen with infection with the virus. While a reactivation of a rheumatic disease can usually be treated very well with anti-inflammatory drugs in the case of a SARS-CoV-2 vaccination, this is only possible to a limited extent in the case of a reactivation of the rheumatic disease as a result of an infection. This is because it would interfere with the immune system’s fight against the virus and therefore be potentially dangerous. With regard to rheumatism, nothing, but nothing at all speaks against vaccination against SARS-CoV-2.
A certain caution is required because of the risk of thrombosis in patients suffering from an anti-phospholipid antibody syndrome. In these patients, vaccination should be done in close consultation with the treating physician. Vaccination success may be weakened under ongoing high-dose glucocorticoid therapy, under therapy with rituximab and possibly under therapy with mycophenolate. Therefore, vaccination should be planned together with the treating physicians. In general, however, the DGRh recommends vaccination against SARS-CoV-2 to every patient with rheumatism.
