How COVID-19 Might Affect People With Rheumatoid Arthritis

People with rheumatoid arthritis (RA) are at a higher risk for infections, including COVID-19, the novel coronavirus that caused the worldwide pandemic. COVID-19 is a highly infectious virus that spreads through airborne respiratory droplets.

Anyone can get COVID-19, but because people with RA are more susceptible to infections, their risk for COVID-19 might be higher. People with RA who develop COVID-19 might also be at higher risk for severe symptoms and complications.

Keep reading to learn about how COVID-19 might affect people with RA, including risk factors, symptoms to look out for, when to see your healthcare provider, and more.

Are You at a Higher Risk for COVID-19 if You Have RA?

Having RA increases your risk for any type of infection. According to a study reported in 2019 in the journal RMD Open, people with RA have an elevated risk for serious infections compared to people with non-inflammatory arthritis or musculoskeletal conditions. This risk applies to all types of infections, including viral, bacterial, and respiratory.

People with RA are more vulnerable to infections when their RA is more active and during flare-ups. Having RA also means you are more likely to end up in the hospital if you develop an infection. This risk is related to a suppressed immune system and the use of RA therapies that add further strain on your immune system. 

A study reported in 2019 in the Journal of Advanced Research looked at nearly 5,600 people with RA over 11 years. Of this group, 289, or 4.2%, were hospitalized for infections, many of which were upper and lower respiratory infections.

COVID-19 can trigger both upper respiratory infections and lower respiratory infections. Upper respiratory infections affect the sinuses, nose, and throat, while lower respiratory infections affect the windpipe and lungs. Many coronaviruses like COVID-19 cause respiratory infections.

According to the University of Texas Southwestern Medical Center, a moderate upper respiratory infection can progress into a serious lower respiratory infection, which could lead to a person with COVID-19 needing ventilator support to breathe.

People with RA may have other conditions called comorbidities, which are defined as the presence of two or more medical conditions in a person. Some of these comorbidities might make it harder to fight off infections like COVID-19. Such conditions might include heart disease, diabetes, and lung diseases like chronic obstructive pulmonary disease.

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Is There An Overestimated Risk?

Despite the elevated risk for infection, people with RA and other rheumatic conditions (i.e., arthritis) are not contracting COVID-19 at higher rates, contrary to what researchers previously feared would happen.

A study reported at the 2020 American College of Rheumatology (ACR) Convergence conference found that people with rheumatic diseases were less likely to become infected with COVID-19. Here, researchers examined COVID-19 rates of infection in people with rheumatic conditions using biologic drug therapies and people with rheumatic diseases not using biologic therapies.

What they found was that despite an increased infection risk, this group was contracting COVID-19 at a rate lower than others in the general problem. Researchers don’t know why this is the case, but they suspect that people with rheumatic diseases are strictly observing social distancing practices and other protective approaches to reduce their risk for COVID-19.

How COVID-19 Might Affect People With RA

One of the concerns healthcare providers have when it comes to people with RA contracting COVID-19 is that their immune systems might be too compromised to fight the virus.

This risk might be even higher if you are an older adult, have other medical conditions, your RA is severe and unmanaged, or you have previously been hospitalized for a respiratory infection. These risk factors also increase the potential for more severe complications of COVID-19. In addition, if your RA is affecting organs or systems other than the joints, particularly the lungs, this could predict worse outcomes with COVID.

Hospitalizations and Death

There has been mixed research on whether people with rheumatic conditions who contract COVID-19 might become more seriously ill.

A study reported in November 2020 at the ACR Convergence found people with autoimmune diseases like RA who develop COVID-19 are more likely to be hospitalized. This group was also more likely to be admitted to an intensive care unit and end up on a ventilator. They are also more likely to develop kidney problems and heart failure associated with COVID-19. A study published in 2023 found that among people with RA who had COVID-19 from March 2020-April 2021, 22% developed severe disease.

In late 2020, researchers from New Zealand and Australia conducted a study that found people with RA had an increased risk of death from COVID-19. That risk mainly came from having a weakened immune system related to the use of immunosuppressive drug therapies. A later study that reviewed data during beginning of the Omicron variant's dominance found that rituximab increased the risk of hospitalization and death, while JAK inhibitors only increased the risk of hospitalization.

Other studies contradict the findings on COVID-19 severity and mortality in people with autoimmune and rheumatic diseases. A review from researchers out of the University of Texas presented at the 2020 ACR meeting found a high number of people with rheumatic diseases who contracted COVID-19 had mild symptoms, and very few died. The review was based on only eight studies, however, and the researchers felt they needed larger studies to look at treatment and disease severity.

Comorbid Conditions

Many studies that were presented at the 2020 ACR Convergence found having a rheumatic disease and another condition could lead to serious COVID-19 complications.

The previously mentioned comorbidity study found that people with RA had higher rates of high blood pressure, chronic kidney disease, asthma, and heart failure before developing COVID-19. Researchers suggested the higher prevalence of these conditions might explain why people with rheumatic diseases had an increased risk of complications.

Corticosteroid Use

Early on in the pandemic, rheumatologists were warning about the risks associated with COVID-19 and corticosteroid use. If your healthcare provider has prescribed corticosteroids, it is likely to treat out of control RA symptoms or an RA flare-up. These drugs shut down your immune system responses, which makes you vulnerable to infections like COVID-19.

If you develop COVID-19 while using a corticosteroid, your risk for complications and death might be higher than for those who are not using these therapies. A metanalysis reported in 2020 in the journal The Lancet concluded that the overall mortality rate for COVID-19 was higher among patients who were using corticosteroids to treat other health conditions.

More recent studies, however, have looked at the viability of corticosteroids for treating COVID-19 and their potential for reducing the duration and severity of the disease.

A study reported in December 2020 evaluated the effectiveness of the corticosteroid drug dexamethasone for managing COVID-19. Here, researchers found a reduced 28-day mortality risk in people with COVID-19 who needed oxygen therapy or mechanical ventilation.

This study led researchers to reconsider their previous position on corticosteroids as they relate to COVID-19. However, the researchers did add that further study was needed to confirm specific benefits and risks connected to corticosteroids and COVID-19.

Long COVID

Long COVID is defined as signs, symptoms, and conditions that continue or develop after an acute COVID-19 infection. Long COVID can include a wide range of new, returning, or ongoing health problems that can last weeks, months, or years.

The symptoms people who experience Long COVID most commonly report include:

• Fatigue
• Fever
• Difficulty breathing or shortness of breath
• Cough
• Chest pain
• Heart palpitations (fast-beating or pounding heart)
• Difficulty thinking or concentrating (sometimes referred to as “brain fog”)
• Headache
• Sleep problems
• Lightheadedness (dizziness when you stand up)
• Pins-and-needles feelings
• Change in smell or taste
• Depression or anxiety
• Digestive symptoms, such as diarrhea or stomach pain
• Worsening symptoms after physical or mental effort
• Joint or muscle pain
• Rash
• Changes in menstrual cycles
  

Studies suggest people with RA may be at increased risk for coronavirus infection and long COVID due to underlying altered immunity, treatment with immunosuppressants, and additional chronic conditions (comorbidities).

One study found people who had a rheumatic autoimmune disease were twice as likely to have long COVID-19 compared to healthy people: 10.8% of people with rheumatic autoimmune disease compared to 5.3% of healthy people. 

Just as there is no single cause of long COVID, there is no treatment that benefits everyone. Researchers are investigating a variety of treatment options, such as:

• Anti-inflammatories
• Metformin (a diabetes medication)
• Low-dose naltrexone—an addiction drug that in small doses can reduce immune and neurologic inflammation
• Physical rehabilitation
• Breathwork
• Chinese herbs

Symptoms to Look Out For

The symptoms of COVID-19 are the same with or without RA. The most common symptoms include:

• Fever
• Cough
• Fatigue
• Sore throat
• Shortness of breath

If you contract COVID-19 and develop symptoms, you will notice these two to 14 days after exposure to the virus.

More severe symptoms of COVID-19 might include:

• A high fever
• Severe cough
• Shortness of breath

These symptoms could indicate pneumonia or acute respiratory distress syndrome (ARDS). However, immunosuppressive drugs, including steroids, can sometimes suppress fever, so this is not a reliable symptom in people taking these medications.

Pneumonia is an infection in which one or both of the lungs become inflamed and filled with fluid, leading to breathing difficulties. Pneumonia caused by COVID-19 often affects both lungs.

If pneumonia becomes severe, it can lead to acute respiratory distress syndrome (ARDS), a type of lung failure. ARDS can be fatal, and people who develop it need to be on a ventilator. If they survive ARDS and recover from COVID-19, there may be lasting lung damage and scarring. Another serious complication of COVID-19 is sepsis (infection in the bloodstream), which can cause serious damage to the lungs and other organs.

Additional symptoms of COVID-19 to watch for include:

• Headache
• Chills
• Loss of appetite
• Confusion
• Loss of taste and/or smell
• Gastrointestinal symptoms like nausea, vomiting, and diarrhea

Joint and muscle aches (myalgia) are also possible, but true muscle weakness and joint inflammation are much more rare.

What to Do if You Develop Symptoms

If you develop symptoms of COVID-19, call your primary care healthcare provider or rheumatologist. They will explain what you should do, which will depend on the symptoms you have.

Do not go to the hospital at the initial onset of symptoms. If you have COVID-19, you can spread it to others. Ask for a telemedicine visit so you can stay home and avoid exposing others. If your healthcare provider thinks you have COVID-19, they will let you know where to go for a COVID-19 test.

If you test positive for COVID-19, your healthcare provider will discuss and prescribe treatments you will need to manage symptoms. You should stay home and self-isolate away from others until your symptoms improve for at least 24 hours. After that, you should continue to practice precautions for the next 5 days.

If you need to leave your home to pick up medications or for a healthcare provider's visit, make sure you wear a mask and keep your distance from other people after you start feeling sick or test positive.

Watch out for dangerous complications of COVID-19. Call 911 if you experience the following symptoms:

• Problems with breathing
• Chest pain or pressure
• Confusion
• Prolonged vomiting or diarrhea, which can lead to severe dehydration
• An inability to stay awake
• Blue lips or a blue face

Treatment

There are several different COVID-19 treatment options available. If you have mild symptoms, you can recover at home and take over-the-counter (OTC) pain relievers, such as acetaminophen (Tylenol) and ibuprofen (Advil and Motrin). Your healthcare provider will advise you to stay hydrated and get plenty of rest.

Your healthcare provider might recommend antiviral medications like Paxlovid (nirmatrelvir with ritonavir) or Lagevrio (molnupiravir) to treat mild to moderate COVID-19 symptoms in people who are more likely to get very sick. These medications need to be started within 5 days of initial symptoms.

With severe symptoms, you might need to stay in the hospital. Your healthcare provider will design a treatment plan for you based on your symptoms, age, and overall health. This might include oxygen supplementation or putting you on a ventilator, a machine that breathes for you.

Other therapies that might be included in your hospital treatment plan include antibiotics like Zithromax (azithromycin), antiviral drugs including Veklury (remdesivir), and steroids, including dexamethasone.

Is the COVID-19 Vaccine Recommended for People With RA?

The Centers for Disease Control and Prevention recommends everyone 6 months and older receive a COVID-19 vaccine. For people 5 years and older, you are up to date if you have received one updated vaccine from Pfizer-BioNTech, Moderna, or Novavax. Those who use immunosuppressive therapies may also receive additional vaccine doses.

Children 6 months to 4 years need multiple doses of COVID-19 vaccines to be up to date, including at least 1 dose of the most recently updated vaccine.

COVID-19 Prognosis With RA

Your outlook and recovery with COVID-19 when you have RA will be different than someone else’s recovery and outlook. According to a 2020 review, recovery will depend on your age and any other health conditions you might have in addition to RA.

According to the review, people who are older, have comorbidities, or have a high degree of immunosuppression are more likely to have a poor outlook. The worst outcomes are connected to people with coronary heart disease or cerebrovascular disease.

COVID-19 in people with severe RA might be associated with heart and lung complications, which can also lead to a poorer outcome.

Summary

Researchers still don’t have a lot of information about the effects of COVID-19 on people with rheumatoid arthritis. But, in general, because you have RA, your risk is higher for infections, including COVID-19 and long COVID.

The best way to manage your outlook and recovery is by keeping your RA and any other health conditions managed in case you contract COVID-19. Steps you can take include the following:

• Take your RA medications as prescribed.
• Keep an adequate supply of medications, or access to refills, if you have to quarantine.
• Do not stop taking any of your RA medications or medications for other health conditions unless your healthcare provider tells you to.

Vaccinations, including boosters, are the most effective way to protect yourself against COVID-19. You should also do what you can to limit your exposure to the coronavirus by wearing a mask, practicing social distancing, and washing your hands often. These general prevention tips are important for everyone and are the best tools to reduce your risk for infection and the spread of COVID-19.

The information in this article is current as of the date listed. As new research becomes available, we’ll update this article. For the latest on COVID-19, visit our coronavirus news page.