Long COVID and Patients with Rheumatic Disease: Perspective from EULAR 2023

By mid-2023, the long-lasting impact of COVID-19 has altered the course of public health for decades to come. The most widespread pandemic since the influenza pandemic rocked the nation in 1918, COVID-19 touched every corner of the globe and continues to place a considerable strain on public health systems despite the World Health Organization declared an end to COVID-19 as a public health emergency.¹

Although lockdown measures and stay-at-home orders appear to be a thing of the past, the lasting effects of COVID-19 are still widespread—evidenced by the growing research emphasis on understanding long COVID. Studies have drawn conflicting conclusions related to risk of long COVID symptoms among people with autoimmune disorders or rheumatic disease, with some purporting increased risk, including an analysis from Holland suggesting patients with inflammatory rheumatic disease had a 53% increase in likelihood of developing long COVID following a COVID-19 infection compared to those without such a disease after developing COVID-19. In contrast, an analysis of the COVID-19 Global Rheumatology Alliance Vaccine Survey suggests the majority of patients with systemic autoimmune rheumatic disorders who contracted COVID-19 experienced complete resolution of symptoms within 15 days.^2,3

The European Congress of Rheumatology (EULAR) annual meeting serves as the foremost international meeting for rheumatologists and other care providers interested in rheumatic disease. At this year's meeting COVID-19 may not have been the subject of as much discussion as it had been during the peak of the pandemic, but EULAR 2023 featured more than 2 dozen abstracts listing COVID-19 directly in the title.

Spurred by the aforementioned discordance in data and with an interest in learning more about the perceptions of long COVID among rheumatologists, our editorial team asked a group of key opinion leaders for their perspective on the topic of long COVID. Included in this group is Lars Erik Kristensen, MD, PhD, scientific director of the Parker Institute, George Karpouzas, MD, professor of Medicine at the David Geffen School of Medicine at UCLA and chief of the Division of Rheumatology at Harbor-UCLA Medical Center, Cozianna Ciurtin, PhD, consultant rheumatologist and associate professor at the University College London, and Brian LaMoreaux, MD, senior medical director with Horizon Therapeutics.

^{(L to R) George Karpouzas, MD; Lars Erik Kristensen, MD, PhD; Coziana Ciurtin, PhD; Brian LaMoreaux, MD
Credit: Lunquist Institute; Parker Institute; University College London; Horizon Therapeutics}

HCPLive: How concerned are you regarding long COVID among patients rheumatic disease?

Kristensen: In terms of long COVID and rheumatic disease patients, I am not concerned from a safety point of view for those that have rheumatic diseases and get COVID. What I could see being potentially concerned about is that we see more and more different phenotype types coming out of a post-COVID infection in patients that were not having autoimmune disorders before but are getting that secondary to coronavirus infection.

I think it's manageable because we know so many millions of billions of people have had COVID-19 around the world, but, definitely, we will see new diseases and we will see sizes of patient populations grow over time. So, that is what I'm a bit concerned about, but it doesn't keep me awake at night.

Karpouzas: I do not know how much more prevalent long COVID is in patients with rheumatic diseases compared to the general population. Most certainly patients with rheumatic disease, because of the medications that we use, can be predisposed to develop COVID, but in terms of the impact of long COVID, I don't have a sense yet. I think we are still exploring this and we're learning about it.

Ciurtin: I think nowadays we have reasonably good data coming from large registries and some of the data will be presented even at this Congress. There is no conclusive evidence that people with autoimmune rheumatic conditions, such as inflammatory arthritis, lupus or any other type of autoimmune conditions, are particularly at risk of developing long COVID. This is quite reassuring.

Although, as we know, it's very difficult to translate this at the individual level. Some patients may develop exactly the same as patients in the general population or without these conditions may develop long COVID, but there is no signal that there is increased risk because they have an autoimmune rheumatic condition.

LaMoreaux: Long COVID is coming and you could say it's already here. Fortunately, a lot of excellent research is coming out about the main symptoms—fatigue, myalgias, and dyspnea, with a lot of other kinds of mixed symptoms.

Rheumatologists have dealt with this in the form of chronic fatigue syndrome, sometimes fibromyalgia gets rolled into these. So, we have some experience, but we need more specific long COVID-directed therapies. These are patients with long-term symptoms, no discernible inflammatory pathology, and no active infection, but they just don't feel like themselves.

There's a massive, massive wave coming post-COVID and I think rheumatologists are going to wind up seeing a lot of these patients because we're the specialty that sees people when they don't feel well and nobody else can find anything. So, having an effective workup, knowing what we can do, telling them what we can do, and maybe even prescribing sometimes. I think it's all much needed and I'm glad that we're progressing on that front.

Editor’s note: Transcripts have been edited for length and clarity.

References:

1. WHO chief declares end to COVID-19 as a global health emergency | UN news. United Nations. May 5, 2023. Accessed June 4, 2023. https://news.un.org/en/story/2023/05/1136367.
2. Boekel L, Atiqi S, Leeuw M, et al. Post-covid condition in patients with inflammatory rheumatic diseases: A prospective cohort study in the Netherlands. The Lancet Rheumatology. Published online May 31, 2023. doi:10.1016/s2665-9913(23)00127-3
3. DiIorio M, Kennedy K, Liew JW, et al. Prolonged COVID-19 symptom duration in people with systemic autoimmune rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance Vaccine Survey. RMD Open. 2022;8(2):e002587. doi:10.1136/rmdopen-2022-002587