The Interplay Between Arthritis and COVID-19
Managing inflammatory arthritis during the COVID-19 pandemic presents a unique challenge for both patients and rheumatologists. The core issue lies in balancing the need to control autoimmune-driven inflammation with the potential risks of using immunosuppressive medications during an active viral infection [1.2.3, 1.4.1]. Severe COVID-19 is characterized by a hyper-inflammatory state known as a "cytokine storm," where the immune system overreacts, causing widespread damage, particularly to the lungs [1.3.7, 1.8.3]. Interestingly, some of the same inflammatory pathways and cytokines, such as Interleukin-6 (IL-6), are involved in both rheumatoid arthritis (RA) and severe COVID-19, leading to the investigation of certain arthritis drugs as potential COVID-19 treatments [1.3.5, 1.8.1].
Initial guidance recommended caution, but as evidence evolved, it became clear that uncontrolled arthritis activity itself is a significant risk factor for poor outcomes [1.8.2]. An arthritis flare-up could necessitate higher doses of corticosteroids, which are associated with an increased risk of severe COVID-19 [1.4.4, 1.7.6]. Therefore, the general consensus from major bodies like the American College of Rheumatology (ACR) has been to continue most disease-modifying antirheumatic drugs (DMARDs) unless a patient develops an active infection [1.2.1, 1.4.2].
Key Medications for Arthritis During a COVID-19 Infection
Treatment decisions must be individualized, weighing the patient's disease activity, medication type, and the severity of the COVID-19 infection [1.2.3].
Janus Kinase (JAK) Inhibitors
JAK inhibitors, such as baricitinib, tofacitinib, and upadacitinib, are targeted synthetic DMARDs used to treat RA [1.2.1]. Baricitinib gained significant attention as it was found to have potential antiviral activity by inhibiting viral entry into cells and also dampening the inflammatory cytokine storm seen in severe COVID-19 [1.2.3, 1.3.5]. The FDA approved baricitinib for treating certain hospitalized COVID-19 patients [1.3.1]. Studies have shown that baricitinib can reduce mortality and the need for ventilation in severe cases, making it a valuable tool for hospitalized arthritis patients with COVID-19 [1.3.4, 1.3.5].
IL-6 Receptor Blockers
Monoclonal antibodies that block the IL-6 receptor, like tocilizumab and sarilumab, are biologic DMARDs for arthritis [1.2.1]. Given that IL-6 is a key cytokine in the COVID-19 inflammatory storm, these drugs were studied extensively [1.8.3]. The RECOVERY trial showed that tocilizumab reduced the risk of death in certain hospitalized patients with COVID-19 who were already receiving corticosteroids [1.3.4]. For arthritis patients with severe COVID-19, ACR guidance suggests that IL-6 inhibitors may be continued in select circumstances through shared decision-making with a provider [1.2.5].
Conventional Synthetic DMARDs (csDMARDs)
This class includes medications like methotrexate, hydroxychloroquine (HCQ), sulfasalazine, and leflunomide [1.2.1].
- Methotrexate and Leflunomide: The general guidance is to temporarily stop these medications if a patient develops a confirmed or suspected COVID-19 infection and resume them 7-14 days after symptoms resolve [1.2.3, 1.7.6].
- Hydroxychloroquine (HCQ) and Sulfasalazine: Early in the pandemic, HCQ was investigated as a potential COVID-19 treatment, but larger trials found it ineffective [1.2.3, 1.2.7]. ACR guidance has suggested that HCQ and sulfasalazine, which are considered less immunosuppressive, may be continued during a COVID-19 infection [1.2.5].
Corticosteroids and NSAIDs
- Corticosteroids (e.g., Prednisone): Chronic use of corticosteroids, especially at doses above 10 mg/day, is linked to a higher risk of severe COVID-19 outcomes [1.2.4, 1.4.4]. However, they should never be stopped abruptly due to the risk of adrenal insufficiency [1.8.4]. Paradoxically, low-dose dexamethasone (a corticosteroid) became a standard of care for treating hospitalized COVID-19 patients requiring oxygen because it helps control hyper-inflammation [1.2.3, 1.4.5]. For arthritis patients, the goal is always to use the lowest effective dose for the shortest possible time [1.5.5].
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Early concerns about NSAIDs like ibuprofen worsening COVID-19 were not substantiated by later, larger studies [1.7.3, 1.7.4]. The World Health Organization (WHO) and other agencies have stated there is no evidence to avoid NSAIDs [1.7.1, 1.7.2]. They can generally be continued for arthritis symptoms, though some guidance suggests stopping them in cases of severe COVID-19 with kidney or gastrointestinal complications [1.7.6].
Comparison Table of Arthritis Medications in COVID-19
| Medication Class | Example(s) | Role in Arthritis | Role in COVID-19 | General Guidance During Active COVID-19 [1.2.3, 1.2.5] |
|---|---|---|---|---|
| JAK Inhibitors | Baricitinib | Reduces inflammation | Reduces inflammation and viral entry; approved for severe COVID-19 | Hold temporarily; may be used for treatment in hospitalized cases. |
| IL-6 Inhibitors | Tocilizumab | Blocks IL-6 cytokine | Reduces cytokine storm; improves survival in severe cases | Hold temporarily; may be continued/used in hospitalized cases. |
| csDMARDs | Methotrexate | Suppresses immune system | None; potential risk | Temporarily stop upon infection. |
| csDMARDs | Hydroxychloroquine | Modulates immune system | Ineffective | Generally safe to continue. |
| Corticosteroids | Prednisone | Suppresses inflammation | High doses are a risk factor; low-dose dexamethasone treats severe cases | Continue at the lowest effective dose; do not stop abruptly. |
| NSAIDs | Ibuprofen | Reduces pain & inflammation | Symptom relief; no evidence of worsening outcomes | Generally safe to continue, unless severe complications exist. |
Post-COVID Arthritis and Long COVID
Some individuals develop new or worsening joint pain after a COVID-19 infection, a condition sometimes referred to as post-COVID reactive arthritis or as a symptom of Long COVID [1.6.1, 1.6.4]. This occurs when the immune system, after fighting off the virus, mistakenly attacks the joints, causing inflammation, pain, and swelling [1.6.4]. Treatment for reactive arthritis typically involves NSAIDs as a first-line therapy to reduce inflammation [1.6.1, 1.6.2]. If symptoms are severe or persistent, doctors may prescribe corticosteroids or DMARDs like sulfasalazine or methotrexate [1.6.3, 1.6.6].
Conclusion
Managing arthritis in a patient with COVID-19 is a delicate balancing act. Key immunomodulating drugs used for arthritis, such as the JAK inhibitor baricitinib and the IL-6 inhibitor tocilizumab, have found a new role in treating severe COVID-19 by taming the inflammatory cytokine storm [1.3.2, 1.3.4]. For most patients, continuing their maintenance arthritis therapy is crucial to prevent disease flares, which pose a greater risk than the medications themselves [1.4.2]. However, upon active infection, certain immunosuppressants like methotrexate should be temporarily paused [1.7.6]. All treatment decisions must be made in close consultation with a rheumatologist, who can provide personalized advice based on the latest clinical evidence.
Authoritative Link: For the latest clinical guidance, consult the American College of Rheumatology's COVID-19 Guidance page [1.5.1].
