Lupus & COVID-19-An Update
Dr. Robert Katz
Professor of Medicine Rush University Medical Center
Northwestern University’s Feinberg School of Medicine
Chairman Medical Advisory Board, Lupus Society of Illinois
Dr. Ben Small
Northwestern University’s Feinberg School of Medicine
COVID-19 stands for a specific type of coronavirus disease that began in 2019. CO is for corona, VI for virus and D for disease.
Many lupus patients are concerned about how they would handle COVID-19 if they contracted the virus. The answer depends on the patient’s age and the severity of the patient’s underlying lupus. Older adults and those with significant major organ involvement like lung disease, kidney involvement and other comorbidities are definitely at increased risk for serious problems should they get COVID-19. But most lupus patients should be able to handle the viral illness well with only mild symptomatology.
COVID-19 Symptoms & When to Take Action
Common symptoms related to the virus include fever over 100 degrees, a dry persistent cough, shortness of breath, loss of smell and taste, sore throat, muscle aches, fatigue and loss of appetite.
Emergency warning signs to seek medical attention immediately include trouble breathing, chest pain/pressure, confusion or bluish lips/face.
People who get very sick from coronavirus with serious lung manifestations, which show up on CT scans along with low oxygen levels, appear to be suffering from an overactive immune system response to the virus. This out-of-control immune response is sometimes called a “cytokine storm.” We don’t have evidence that lupus patients are more or less likely to get cytokine storm.
If you think you might have COVID-19 based on the symptoms mentioned above, in addition to self-quarantining, you could contact your rheumatologist, primary care physician, urgent care facility, or emergency department by phone to review your symptoms. Your health care professional will have instructions for how to proceed with testing and accessing care while minimizing exposure to others. In Illinois, only health care providers can order COVID-19 tests. (IDPH Who Should I call? COVID-19 Website: http://www.dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/coronavirus/personal-guidance-and-testing)
Many physicians are using telehealth with either video or phone sessions to help care for all patients. It is likely that doctors will not start seeing patients for regular office visits until May or later.
The CDC is suggesting that people can be released from self-isolation if there has been no fever for three days, other symptoms have improved with the possible exception of a lingering cough, and it has been more than seven days since the onset of symptoms.
Medications and Treatments for COVID-19
For people with lupus, the current recommendation is not to discontinue lupus medications, including immunosuppressive drugs, if your disease is under control and you are feeling well. However, if a lupus patient is stable and elects to stop their immune suppressive medication, that is an option worth considering, though not mandatory in any way. That idea should be discussed with your physician if you are thinking about discontinuing immunosuppressive medicine.
You can certainly have a conversation with your rheumatologist before going in for an IV infusion, such as Benlysta for lupus. These infusions are still being done in rheumatology offices and infusion clinics to keep lupus and other rheumatic diseases under control.
Hydroxychloroquine (HCQ) generic of Plaquenil, as a treatment for COVID-19 needs to be evaluated further in clinical trials; however, many of our lupus patients are already taking this medication. Some lupus patients have asked to add HCQ/Plaquenil to their regimen, which is reasonable at this time.
Like other medications, be sure to take HCQ/Plaquenil as your physician prescribes.
The available HCQ/ Plaquenil studies have very few patients, so far around 120, and have significant flaws in study design. We need more data to inform decisions about its use, but the toxicity is minimal. Physicians have been prescribing Plaquenil for many decades and have rarely seen any serious problems. It is not suggested that HCQ/Plaquenil be used preventatively at this point, although some people are taking it if they are directly exposed to somebody who has the COVID-19 virus.
HCQ/Plaquenil is not always available because so many people have stocked up on it. Pharmacists are often limiting the supply, but lupus patients can generally get it. It is easier for patients to get HCQ/Plaquenil if it is on their previous pharmacy record. We have had some long-standing lupus patients who want to start HCQ/Plaquenil, and it has not been difficult to order as a new prescription for these patients.
Many pharmacies are offering free delivery during the COVID-19 pandemic. Alternatively, your pharmacy may be able to mail your prescription to you if it is not urgent. Check with your local pharmacy to make arrangements.
In addition to HCQ/Plaquenil, some preliminary studies, especially a French research paper, recommended the use of 500 mg of azithromycin, which comes as part of a Z-Pak, to be used for approximately five days, one a day. The efficacy of this treatment is unclear, but there is not much else right now in terms of effective treatments. That will change, especially with future anti-viral therapies.
Companies like Pfizer are investigating the use of Xeljanz (tofacitinib), which is commonly used for rheumatoid arthritis and psoriatic arthritis. Other companies are looking at Actemra (tocilizumab) and Kevzara (sarilumab), which are interleukin-6 inhibitors to treat “cytokine storm.” These therapies are only for those patients who are extremely ill, and these studies are ongoing investigations with no proven effectiveness at this point.
Another drug being tested is remdesivir, an anti-viral medication given intravenously, and used for people who have active coronavirus symptoms. These study results are not yet available.
We need to develop better, more effective treatments that start early in the disease process. Most COVID-19 interventions are salvage therapies for very sick patients rather than early treatment. Patients who have recovered from COVID-19 are sometimes able to donate their blood, so that antibodies to the COVID virus are separated and given to other sick patients to help them recover. Phase one testing has started for a COVID-19 vaccine. Timelines will depend on the safety and efficacy of ongoing clinical studies, with estimates for vaccine availability between 12 and 18 months.
COVID-19 Testing Updates
Abbott has recently released rapid testing supplies. Everyone wants to increase testing capacity in both supplies and test processing. The clinical validation of the Abbott Alere rapid testing has been challenging and needs to be compared with the current validated testing system called polymerase chain reaction (PCR), which determines whether the COVID-19 RNA (ribonucleic acid) is present in nasal secretions or throat swabs. The Abbott Alere rapid testing is a way of making certain that the PCR diagnosis is accurate.
We need to better understand this Abbott Alere testing system, but the results are available very quickly, usually within 15 minutes from a nasal swab. The test targets the coronavirus RdRp gene. We had a patient this week who went for COVID testing, and a nasal swab analysis showed she had a negative result after only 15 minutes. Otherwise there is often a seven-day wait period for the results of the PCR RNA COVID test that is currently available.
Patients with COVID-19 can be re-tested to see if they no longer have the virus. The testing is done through a nose and throat swab at this time.
Blood testing for antibodies to the virus is not yet available. For most other viruses, antibodies are determined through blood testing. The IgG antibody indicates that you had the virus previously (for example, people who had measles as a child are IgG antibody positive for the measles virus), and IgM antibodies indicate that you currently have the active virus.