Update on management of COVID-19 infection and vaccination in systemic lupus erythematosus

ABSTRACT

Patients with immune mediated rheumatic and musculoskeletal diseases (RMD), including lupus, may develop more severe COVID 19 infection than the general population. Several medicines used in treatment of systemic lupus erythematosus (SLE), such as glucocorticoid, increases the risk of Covid 19 infection, especially at dose higher than 10 mg. The use of immunosuppression may have a role in altering the immune response to infection, therefore the experts recommend to use the good but safe alternatives, if available. However in manage acute or critical condition, established therapies may be more beneficial then alternatives to control the disease activity. Evidence for discontinuing immunosuppressants in RMD patients with COVID-19 is low, but the experts strongly recommended discontinuing them and weakly recommended to re-introduce them at least 2 weeks after recovery from acute COVID-19, but this may need to be individualized based on the clinical scenario and the judgment of physician. Lupus patients are recommended to receive SARS-CoV- 2 vaccine, as long as they do not have an allergy to vaccine components. Several studies revealed that there was no significant change in lupus disease activity after vaccination, however a study using BNT162b2 COVID-19 vaccine reported mild local reactogenicity in SLE and RA patients, such as redness and swelling. More frequent systemic reactogenicity, such as fever, fatigue, headache, chills, muscle and join pain, and vomiting, however, not more severe compared to healthy controls. This study adds to the notion that the vaccine is safe and well tolerated in patients with SLE and RA. Neutralizing antibody levels after COVID-19 vaccination were significantly lower than control population. The risk factors for reduced immunogenicity included older age and treatment with glucocorticoids, mycophenolate, rituximab and abatacept, and type of vaccines. Adjusting the immunosuppression dosage schedule was suggested and considered an individual condition. A COVID-19 vaccine booster is encouraged for patients with autoimmune inflammatory rheumatic disease, including lupus. If they have completed the primary COVID vaccine series of 3 doses and are expected to have mounted an inadequate vaccine response, they should receive supplemental doses (e.g., >=2 additional boosters, for a total of five doses) as recommended by the CDC for immunocompromised individuals.