COVID-19 Risk for Chronic Conditions Like Lupus and Rheumatoid Arthritis

Certain dietary and lifestyle tweaks may help to reduce the risk of contracting the virus in those already living with autoimmune and inflammatory conditions. Plus, the science behind oxidative stress and cytokine storms.

COVID-19 has shuttered entire nations while the medical and scientific community hastens to understand this novel virus and works to develop protocols and treatments that will limit its damage. We know the virus affects different populations differently, and those living with chronic inflammatory conditions such as systemic lupus erythematosus (SLE, lupus) and rheumatoid arthritis may respond to the virus differently than those without autoimmune conditions.

While the research to date is not yet conclusive, we can draw on the information we have to lower risks and better understand the relationship between inflammation, susceptibility to COVID-19 infection, and the potential severity of our body’s reaction if we do contract the virus.


iStockPhoto (onurdongel)The coronavirus is a non-living organism that invades and hijacks our cells, subsequently manipulating them into reproducing RNA. To do this, the virus must “dock” in our body by attaching to a specific cell surface receptor (CSR), namely ACE2 receptors.

How COVID-19 Infects Our Innate Immune System

To better comprehend how COVID-19, clinically termed SARS-CoV-2, may affect our bodies, we must first understand how the virus infects us and, second, how our immune system responds.

The coronavirus is a non-living organism that invades and hijacks our cells, subsequently manipulating them into reproducing RNA. To do this, the virus must “dock” in our body by attaching to a specific cell surface receptor (CSR), namely ACE2 receptors, which are common in the body, and can be found throughout the respiratory and digestive systems. The virus then fuses with the ACE2 receptors, assisted by the enzyme TMPRSS2, which is commonly found in your airway and alveolar tissue (ie, the tiny sacs in our lungs that allow oxygen and carbon dioxide to move between the lungs and the bloodstream).

The co-localized presence of ACE2 and TMPRSS2 is one reason why the COVID-19 virus has become such a scary respiratory illness; our bodies have lots of parking spaces for the virus to fill. Some individuals have higher or lower concentrations of ACE2 receptors than others. For example, men typically have more ACE2 receptors than women, which may explain why they have reportedly been more susceptible to the virus. ACE2 receptors also tend to become denser as we age – in both men and women – due to oxidative stress.


Getting Technical: Oxidative Stress, Inflammation, and the Cytokine Storm

Oxidative stress occurs when there is an imbalance in reactive oxygen species (free radicals) and free radical scavenging systems in the body. When there is a severe and acute imbalance in this homeostasis (as seen in some patients with COVID-19), oxidative stress can lead to tissue and cell damage. Lifestyle factors can also increase oxidative stress, sometimes leading to chronic inflammation. Obesity, insulin resistance, type 2 diabetes, and other comorbidities associated with the metabolic system have been linked to increased oxidative stress. 

Understanding the enzyme ACE2 can help in understanding the body’s reaction to the SARS-CoV-2 virus. ACE2 is a redox enzyme and plays an important role in inflammation.1 It is also part of the renin-angiotensin system – that’s the system that regulates blood pressure – by playing a role in the dilation of blood vessels. ACE2 is also involved in cardiac rhythm, lung function, and glucose metabolism.2The dysfunction of this enzyme can lead to diabetes, high blood pressure, and heart disease.

Our own immune response to this novel virus is another crucial factor. “In patients with severe respiratory failure from SARS-CoV-2 we are seeing an imbalanced immune response that results in a cytokine storm and exaggerated inflammatory response,” explains USC School of Pharmacology researcher, Roger Allyn Clemens, DrPh. A recent study (to be published in June) specifies that interleukin-6 (acting as a cytokine) may be a mediating factor in this severe inflammatory response. Lymphopenia (reduced levels of certain white blood cells), was also present in patients who entered into severe respiratory failure. This immune dysregulation is associated with sustained cytokine production and hyper-inflammation.The study’s researchers treated a small group of patients with the interleukin-6 blocker, tocilizumab and saw an increase in immune regulatory factors. 

istockPhoto (toeytoey2530)The body’s reaction to the novel coronavirus is modified by our innate immune system but the cytokine storm is similar to the inflammatory response people often experience with autoimmune disorders such as lupus and rheumatoid arthritis.

The body’s reaction to the novel virus is modified by our innate immune system (the system responsible for fighting novel infections) but the cytokine storm is similar to the inflammatory response people often experience with autoimmune disorders, which is predominantly regulated by the adaptive immune system. Both rheumatoid arthritis and lupus, for instance, can present with lymphopenia and decreased HLA-DR expression, leading to inflammation. Research suggests that dysregulation of the innate immune system also plays a role in both rheumatoid arthritis4and lupus.5


Could I Be More Susceptible to the Coronavirus?

The question is, do these pro-inflammatory autoimmune disorders increase susceptibility to infection or to a severe reaction? The answer depends on many factors, including a person’s specific diagnosis, medication regimen, and lifestyle.

Patients with rheumatoid arthritis, for example, typically have dramatically less ACE2 receptors, which explains why they are often at an increased risk for cardiovascular disease. But while they have fewer parking spaces for COVID-19, the increased risk of cardiovascular disease should be closely monitored during the pandemic. Dr. Clemens explains that, “The importance of ACE2 functions are underscored relative to cardiovascular disease, specifically as they relate to blood pressure modulation.”

Lupus involves systematic inflammation – that is, throughout the whole body – and affects patients differently. If a patient has another condition in addition to lupus, such as a respiratory problem, that could put them at a higher risk. The Lupus Foundation  for America warns that the risk of infection is greater for people with lupus than for the general population.6

Patients with chronic systematic inflammation live with dysregulated immune systems, but doctors aren’t yet certain if this puts them at an increased risk for a cytokine storm. Dr. Clemens emphasizes that, “the redox system relative to the current pandemic is under investigation.” He further explains that stopping a patient from entering the cytokine storm is an important part of success and survival if infected with COVID-19. The goal is to avoid ever needing a ventilator. Researchers at USC’s Keck School of Medicine are testing the anti-inflammatory drug baricitinib (commonly used for rheumatoid arthritis), as a treatment for coronavirus patients. It has become clear to many researchers that preventing this cytokine storm could be a key part of treating the novel coronavirus.


If You Are At Higher Risk, There Are Preventive Steps You Can Take

Continue Taking Your Medications

If you are taking an immunosuppression therapy to treat your lupus or rheumatoid arthritis, it is recommended that you continue with that medication. (More on the coronavirus and immunosuppressants.)

The missing headline in all this, is the importance of balance. Dr. Clemens reminds us that not all cytokines are bad. As part of our natural immune response, we have pro-inflammatory and anti-inflammatory cytokines. It is the imbalance and dysregulation of this system that causes chronic inflammation in some cases, and acute cytokine storms in others.

Some researchers believe that the modulating this homeostasis (your internal equilibrium) and managing oxidative stress may help manage inflammatory autoimmune disorders. It may also be a novel approach for the clinical management of COVID-19, shares Dr. Clemens.


Consider Dietary Supplements

Generally, the healthier you are, the easier it is for your body to fight infection with a balanced response. Unfortunately, staying well is not always as simple and eating an extra handful of blueberries and getting enough sleep—although this is an important part.

Dr. Clemens says that, “The role of dietary antioxidants remains questionable, since the innate antioxidant system overwhelms the system to protect the host.” Still,  Dr. Clemens believes that understanding redox nutrition (to maintain homeostasis and prevent oxidative stress) can play an important role in the management of disease.

Concerning dietary management, research is inconclusive, but some nutrients may play a beneficial role:

  • Zinc may help to prevent the virus from replicating itself (making more copies) within the host.
  • Selenium, a mineral associated with the antioxidant enzyme, glutathione peroxidase, is a mineral with potential anti-inflammatory and antiviral activities (selenium deficiency could increase the risk of viral infections).7
  • Vitamin D plays a crucial role in the body’s immunity and inflammatory pathways and may reduce the risk of contracting COVID-19. One study recommends a dosage of 10,000 IU/d of vitamin D3 for a few weeks to rapidly raise 25(OH)D levels, followed by 5000 IU/d.

The best sources of these nutrients are a balanced diet and daily doses of sunlight, although in some cases, supplementation may be advised. Always check with your doctor before adding supplements to your daily routine. To protect your health, follow guidelines to social distance, frequently wash your hands, and maintain current immunosuppressant medications.

There is still much that we don’t know concerning susceptibility and response to the novel coronavirus, COVID-19. For people with chronic inflammatory conditions such as lupus and rheumatoid arthritis, there seems to be an increased susceptibility but the risk is not yet fully understood. Remember, balance is key. The body strives for homeostasis and you can help by living a healthy lifestyle.

Updated on: 06/17/20
Continue Reading:
Immunosuppressants and Coronavirus: Here is What You Should Know