Dear Dr. Aviva, Given I am 56 and have Hashimoto's – an autoimmune condition – am I at higher risk for getting COVID-19? Should those of us with autoimmune conditions consider that to be an “underlying condition” that puts one at higher risk of having a more severe reaction if infected with the coronavirus. Thank you so much for your help and balanced information in this time. Sincerely. JM.
In this article I address the overall risks of COVID-19 with various autoimmune conditions, as well as risks for those of you on immunosuppressive medications. This information is not meant to replace your doctor’s advice, and should merely serve as a starting point for a conversation with your health care provider, and to raise your personal health awareness. And I hope it provides you with a sense of support and reassurance.
Overall Risk with Autoimmune Disease
Many of you with autoimmune diseases, particularly with Hashimoto’s, have written to me with worries about an increased risk of contracting COVID-19 if you have AI disease. I know how scary it is to hear about immunosuppression, high risk, and COVID-19 and wonder if that applies to you. Immunosuppression is a general term that describes the lack of an appropriate response by the body to fighting diseases and organisms that may be harmful – such as viruses and certain bacteria. Having a weakened immune system can occur for many reasons including medication, recent surgeries, age, genetics, or having a chronic illness. Not all individuals with autoimmune disease, however, are immunosuppressed; in fact, some autoimmune diseases are due to an overactive immune system, and not all autoimmune disease medications suppress your immune system. However, even those that do may be essential for you at this time.
Okay, I’m not going to sugar coat this: People with some autoimmune conditions – though not all – are probably at higher risk of contracting the virus and may be at risk for more serious outcomes. This may be because of the condition itself and/or the medications that a person takes to treat their condition.
Because the virus is so new, there’s not much formal research to go on and so medical experts are recommending that most people with autoimmune conditions consider themselves as high risk and follow extra precautions accordingly. Per the US Centers for Disease Control and Prevention these include:
- Stock up on supplies.
- Take everyday precautions to keep space between yourself and others.
- When you go out in public, keep away from others who are sick, limit close contact, and wash your hands often.
- Avoid crowds as much as possible.
- Avoid non-essential air travel.
- During a COVID-19 outbreak in your community, stay home as much as possible to further reduce your risk of being exposed.
Not All Autoimmune Conditions Carry the Same Risks
However, not all autoimmune conditions appear to increase risk – and some may not increase risk appreciably, if at all.
Below is a table of the current opinions of medical experts at the time of this writing; however, new information is coming out every day and so it’s important you stay in contact with your healthcare provider.
Be Aware of Atypical Symptoms
In most people, COVID-19 is an uncomplicated respiratory infection with symptoms not dissimilar to flu. However, immunocompromised individuals may have an atypical presentation of symptoms, for example, people with uncomplicated upper respiratory tract viral infection may have non-specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, muscle pain or malaise. Those who are immunocompromised may not have typical symptoms; they may present with dehydration, sepsis, or shortness of breath, and may be more at risk of developing the more severe complications associated with this condition including mild to severe pneumonia, Acute Respiratory Distress Syndrome, and septic shock.
This risk is likely compounded in those already at high risk including:
- people aged 65 and over
- pregnant women
- children and adults with an underlying health condition (such as diabetes, heart or respiratory disease)
- children and adults with weakened immune systems as the result of conditions such as HIV and AIDS, or medicines such as steroids and chemotherapy.
Autoimmune Conditions and Specific Recommendations
Starting with the good news, based on the information we have from China, there is currently no reason to believe that people with thyroid problems are at any increased risk from this new virus. It does not appear that thyroid disease, particularly Hashimoto’s, increases one’s risk of developing COVID-19 unless you fall into another high risk category above. Of note, SARS, a related coronavirus that caused an epidemic starting in 2002, albeit one with much more severe consequences than COVID-19, may be responsible for thyroid damage, so if you do experience COVID-19 infection and have autoimmune thyroid disease, it’s prudent to monitor your symptoms for any changes, and if changes are noticed, to ask your health care provider to order a basic thyroid lab panel. However, at this time, there’s no reason to suspect that COVID-19 will cause thyroid damage.
Rheumatoid and Inflammatory Arthritis
According to the Arthritis Foundation, quoting Kevin Winthrop, MD, a specialist in infectious disease epidemiology at OHSU School of Medicine in Portland, Oregon, based on what we know at this time it’s unclear whether individuals with Rheumatoid arthritis (RA), the autoimmune form, or inflammatory arthritis with high disease activity have an increased risk of COVID-19 as a result of immune system dysregulation. The greater concern seems not to be from COVID-19 itself, but from secondary bacterial infections following COVID-19 infection. To date, however, neither form of arthritis has been flagged as a high-risk condition raising risk of COVID-19 infection or severity.
Inflammatory Bowel Disease (IBD)
IBD includes Crohn’s Disease and Ulcerative Colitis. Both are due to an overactive immune system, and are often treated with immune modification or immune suppression. IBD patients on immunosuppressive medications are, in general, more susceptible to infection. Specifically, being on steroids or immune modulators like azathioprine or 6-mercaptopurine or methotrexate can increase an IBD patient’s risk for viral infections. To date, we don’t have specific IBD research on COVID-19, but some individuals with these conditions may have an increased risk. This likely depends on the extent or severity of your disease, how active it is currently, and whether and which immunosuppressive medications you’re taking. Due diligence to prevent infection is incredibly important, and be aware of the possibility of atypical symptoms and greater disease severity. If you are on immunosuppressive medications, talk with your health care provider about any increased risks and guidance she/he may have for you at this time. The Crohn’s/Colitis Foundation recommends staying on your IBD medications as inflammation due to IBD can lead to complications and damage to your intestinal tract. For additional information about medications, see Do Immunosuppressive Medications Increase Risk of COVID-19?, below in this article.
Celiac Disease Foundation Medical Advisory Board member, Dr. Alessio Fasano, Director of the Massachusetts General Hospital Center for Celiac Research and Treatment, stated that people with celiac disease are not considered immunocompromised, but may be more susceptible to COVID-19 if they have “active celiac disease.” According to Fasano, if celiac disease is well-treated then susceptibility is considered to be the same as in the general population.
People with lupus are at higher risk for a number of types of infections, including colds, flu, and other viruses, and COVID-19 is probably no exception. If you have lupus, I would touch base with your health care provider by phone, email, or medical portal if you have one, about any special precautions or symptoms you should be aware of, and I would approach your environment of course, not with panic, but as if you are at higher risk, observing a greater level of diligence about protecting yourself from exposure. You should plan ahead according to CDC guidelines should you need to stay at home to prevent exposure (self-quarantine), and be more attentive to the possibility of more severe symptoms and the need for medical care should you experience a higher level of severity.
Type 1 Diabetes (as well as Type 2 and Gestational Diabetes)
Diabetes and other chronic medical conditions which are more common in individuals with diabetes, can make people with this condition more vulnerable to infections and to serious complications. Uncontrolled diabetes is especially significant, as hyperglycemia can impair immune function. Perhaps one of the biggest concerns at this time is running out of insulin for those with insulin diabetes, and this is perhaps most significant with those with Type 1 diabetes. It’s essential to talk with your health care provider about having a 60- or 90-day supply of your medications on hand at home should you be unable to otherwise obtain it (quarantine, shortages), and to follow all CDC precautions for high-risk individuals.
Multiple Sclerosis (MS)
As with Lupus, likely given the magnitude of immune dysregulation in MS, and also the likelihood of being on immunosuppressive medications or steroids, sorry to say, there is also a probable increased risk of susceptibility to and severity of illness from COVID-19 infection. Again, this isn’t a cause for panic, just a reminder to check in with your health care provider by phone, email, or medical portal if you have one, to discuss any specific considerations for your situation, and to practice a higher level of vigilance to prevent exposure. You should also plan ahead according to CDC guidelines should you need to stay at home to prevent exposure (self-quarantine) and be more attentive to the possibility of more severe symptoms and the need for medical care should you experience a higher level of severity.
The National MS Society’s National Medical Advisory Committee recommends the following:
- People with MS should follow CDC guidelines and these additional recommendations for people at risk for serious illnesses from COVID-19.
- People with MS should continue disease modifying therapies (DMTs) and discuss specific risks with their MS healthcare provider prior to stopping a DMT.
- Before starting a cell depleting DMT or a DMT that carries warnings of potentially severe increase in disability after stopping, people with MS and their MS healthcare providers should consider specific risks (e.g. age, comorbid health conditions, location) and benefits.
Do Immunosuppressive Medications Increase Risk of COVID-19?
Several of you have also specifically asked if you’re at extra risk because you take medicines that suppress your immune system? The biggest concern is that a suppressed immune system could increase susceptibility, allow for more rampant viral replication, or lead to more serious infection and symptoms.
At this point, unfortunately, the answer is still “we just don’t know.” Limited data does suggest that many of the drugs commonly used to treat autoimmune disease and some form of inflammatory arthritis (i.e. Remicade, Enbrel and Cimzia, the JAK-inhibitors), and corticosteroids including prednisone, may increase risk of developing more severe viral infection.
Here’s an overview of autoimmune disease medication risks. Do not discontinue any medications without talking with your health care provider first; the consequences could outweigh your risk of COVID-19.
- The following drugs are not considered immunosuppressives and are not thought to increase COVID-19 risk at this time: mesalamine (Asacol, Apriso, Canasa, Delzicol, Lialda, Pentasa, Rowasa) or other aminosalicylates
- Immune suppressing medications:
- If you are taking steroids (prednisone/prednisolone) for any reason, be sure to take extra precautions by following the CDC’s recommendations for risk reduction and talk to your healthcare provider, because steroids can suppress your immune system. Discuss whether it is possible to lower your dose or get off steroids with your healthcare provider.
- Immunomodulators like thiopurines (azathioprine, 6-mercaptopurine, cyclosporine, methotrexate), and the JAK inhibitor tofacitinib (Xeljanz, Olumiant and Rinvoq) can inhibit immune response to viral infections.
- Biologics/Biosimilars, for example, certolizumab pegol (Cimzia), adalimumab (Humira®), infliximab (Remicade), golimumab (Simponi), infliximab-abda (Renflexis), infliximab-dyyb (Inflectra), infliximab-qbtx (Xifi), ustekinumab (Stelara), and vedolizumab (Entyvio) are immune suppressing drugs.
One recent study found that in people with heart disease, hydroxychloroquine (Plaquenil) did not increase infection risk, while methotrexate increased infection risk just slightly.
None of these have been specifically been studied yet in relation to COVID-19, however at this time it seems prudent for individuals on immunosuppressants and/or biologics to limit unnecessary travel and large gatherings.
Don't Panic, Be Smart
Given the uncertainty and potential risk, again, please don’t panic – but be smart and proceed with an increased level of vigilance about prevention, doubly so if you also have additional high-risk factors as described earlier. Also, please visit my website where over the next few days I’ll be posting an article on the best things you can do to support your immune health.