Rheumatoid Arthritis and COVID-19: What to Know

People with rheumatoid arthritis (RA) are at a higher risk for infections, including COVID-19. The risk of getting COVID is particularly high during RA flare-ups when the immune system is already compromised. Additionally, people who take immunosuppressant medications are at an increased risk of COVID-19 infections, along with severe symptoms and complications.

If you have RA and test positive for COVID, contact your healthcare provider for advice. The symptoms of COVID, such as fever, cough, and fatigue, are the same with or without RA. If your symptoms are mild, you may be able to recover at home. Staying up to date with COVID vaccinations can help reduce the risks and severity of coronavirus infection.

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

Yes, having RA increases your risk for any type of infection, including COVID-19. 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 SARS-CoV-2, the virus that causes COVID-19, cause respiratory infections.

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 (comorbidities), your RA is severe and unmanaged, or 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

COVID-19 vaccination can help people with RA avoid serious outcomes if they are infected with the virus. A 2022 study found that unvaccinated individuals with RA were more likely than those in the general population to be hospitalized and die from COVID.

The risk of death mainly comes from having a weakened immune system related to the use of immunosuppressive drug therapies. A later study that reviewed data during the 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.

Even vaccinated people with RA are more likely than those in the general population to become infected with COVID and be hospitalized. However, getting booster vaccinations and sticking to preventative strategies may be able to help lower this risk.

Comorbid Conditions

People with RA may have 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.

Aside from comorbidities, altered immunity and treatment with immunosuppressants, including glucocorticoids and disease-modifying antirheumatic drugs (DMARDs), likewise increase the risk of developing COVID in people with RA.

One 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 meta-analysis 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 published in December 2020 evaluated the effectiveness of the corticosteroid drug dexamethasone in managing COVID-19. 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 for COVID-19. However, the researchers added 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

Can COVID Trigger Reactive Arthritis?

Some evidence suggests that COVID can cause reactive arthritis in the post-infectious stage by attacking the musculoskeletal system.

Post-COVID reactive arthritis can affect different parts of the body, especially the joints in the legs like the knee, ankle, and foot. Most people have mild joint swelling, inflamed tendons, or fluid build-up in the affected areas. Some have additional symptoms like conjunctivitis (pink eye) or mild skin conditions.

Most cases of reactive arthritis develop within a few days to four weeks after the COVID infection resolves. It is usually temporary and resolves within a few days of onset.

Reactive arthritis is not exclusive to COVID-19. Similar occurrences have been reported following other viral and bacterial infections, including HIV, dengue, and salmonella infections.

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 five days.

If you need to leave your home to pick up medications or for a healthcare provider’s visit, 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 five 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 antiviral drugs such as Veklury (remdesivir) and steroids such as dexamethasone.

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

People with RA are recommended to get vaccinated. Vaccination can help reduce the risks and severity of coronavirus infection.

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, at least two months after receiving their latest dose.

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. People with RA tend to experience severe outcomes. However, outcomes are improving.

These factors affect whether people with RA experience severe disease or hospitalization:

• Having a comorbidity, including obesity, hypertension (high blood pressure), chronic lung disease, diabetes, and cardiovascular disease
• Taking corticosteroids at a dose of 10 milligrams or more
• Being 65 years or older

Taking measures to protect yourself can improve your outcome if you are diagnosed with COVID-19 or get COVID more than once. You can do this by wearing a mask in crowded indoor spaces, staying up to date with vaccines and boosters, and keeping your arthritis well controlled.

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 don’t know a lot yet about how COVID-19 affects people with rheumatoid arthritis (RA). But if you have RA, your chances of getting infections like COVID-19 are higher. To stay healthier if you do catch COVID-19, try to keep your RA and other health issues under control, and take your medications as your healthcare provider told you to.

Getting vaccinated, including booster doses, is the best way to protect yourself from COVID-19. You can also lower your risk by wearing a mask, keeping a safe distance from others, and washing your hands often. These simple steps help protect you and others from getting sick.

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.