This year we focused on the pandemic and the related health questions from our program members. Weijia Yuan, MD, hosted a virtual Q&A forum titled "Lupus & COVID-19," during which she addressed various areas of concerns in this bilingual Chinese session. Dr. Yuan is Assistant Attending Rheumatologist at Hospital for Special Surgery and NewYork-Presbyterian Lower Manhattan Hospital, and Assistant Professor of Medicine at Weill Cornell Medical College.
The following is the transcript of Dr. Yuan’s Q&A, facilitated by Eliza Ngan-Dittgen, LANtern program supervisor:
Eliza: The first few questions are related to compromised immune systems.
Dr. Yuan: Hi, everyone. Regarding COVID-19 and lupus patients, first of all, COVID-19 virus is a very novel virus. We still don't know much about the virus and the situation is evolving. So, we need to refer to what we already know about viral infection in lupus patients. Are lupus patients at higher risk for contracting COVID-19? Well, lupus patients are at a higher risk of getting infections in general due to dysregulated immune system. It’s reasonable to speculate that lupus patients are more susceptible to contract COVID-19. However, COVID-19 is a highly contagious virus. Therefore, everyone is at high risk of contracting the virus if exposed to large enough amount of virus within certain period of time. So the additional risk for contracting COVID-19 due to lupus is not as significant in the situation where baseline susceptibility is high to begin with.
Eliza: Now the next question is, will lupus patients get more severe infection if they do contract the virus?
Dr. Yuan: COVID-19 not only causes direct damage in tissues and organs, it also causes exaggerated immune response known as cytokine storm that further causes damage. Because lupus is a chronic autoimmune inflammatory disease, when triggered by viral infection, patients can potentially have exaggerated inflammatory response. So it’s reasonable to think that lupus patients may be at higher risk for having more severe infections. Is it true based on what we have observed in our patients during the pandemic? We currently still don’t have adequate data to draw a definitive conclusion. However, from limited studies in other parts of the world and in US, rheumatology patients do not seem to have worse COVID-19 infection outcome as compared to general population. Is this due to the fact that most rheumatologic patients are female while male patients are at higher risk for getting more severe disease? Or does the immunomodulatory treatments play a protective role in our patients? We need more data to know the answer.
Hydroxychloroquine (HCQ) is commonly used in lupus patients. It’s also been used experimentally in COVID-19 patients. Does HCQ decrease the severity of COVID-19 infection in lupus patients? There was a study in France that looked at 17 lupus patients on HCQ. These patients do not appear to have more severe disease. But keep in mind this is a very limited study with very few patients.
Eliza: OK, the following question – we have many questions that are related to medications and treatment, and Dr. Yuan just mentioned HCQ. HCQ has been mentioned in the media a while ago. People are still curious whether it can prevent contracting COVID-19. HCQ can cause vision and heart rhythm problems. Can it still be used in lupus patients who has vision and heart problem?
Dr. Yuan: Thank you. HCQ has been around for about 70 years. It was first used as an anti-malaria drug. It’s been used in treating rheumatologic diseases for the past few decades and has proved to be a safe medication. It’s one of the very few medications that we use in pregnant patients. Can HCQ prevent COVID-19 infection? Since COVID-19 is a highly contagious virus, it would not be realistic to expect a medication to completely prevent the infection. Again, avoiding potential exposure by taking precautions is key. No one is invincible to the virus. Being on HCQ for lupus should certainly not be considered "being protected." HCQ prevention trial is ongoing in healthcare workers in the country. We should get more information when the results are available. Will HCQ reduce the severity of COVID-19 infection? We need more trials in early and mild COVID-19 patients to know the answer.
Retinopathy (disease in the retina) is a potential side effect of HCQ but it’s very rare. Chloroquine has higher retinal toxicity risk than HCQ. Chloroquine is used in some parts of the world but not really in US. The recommended regular eye exam every six months with an ophthalmologist (eye doctor) will identify early changes. There was a study to look into blind patients who also happened to be on HCQ. The causes of their blindness were all attributed to other, obvious reasons.
Is HCQ safe for the heart? It may prolong QT interval* seen on an electrocardiogram (EKG) when combined with certain other medications. Prolonged QT interval can cause arrhythmia (irregular heartbeat) in patients with long QT syndrome, which is a rare heart condition. If you've ever had an EKG once in your life, you would know if you have long QT syndrome or not. Unless one has an underlying arrhythmia or long QT syndrome, HCQ is generally considered safe for the heart. I've had patients who saw cardiologists during the pandemic asking if it is OK for them to continue to take HCQ. The answer has been "yes."
Prednisone is a common medication for lupus patients. Since prednisone lowers the immune system, will it increase the chance for contracting COVID-19? First of all, prednisone should never be stopped abruptly as it can cause a potentially life-threatening withdrawal condition called adrenal insufficiency. Always speak to your rheumatologist if you want to change your prednisone dosage. Although in theory, lowering the immune system would increase infection risk in general, having uncontrolled inflammation raises infection risk as well. So by staying on immunosuppressive therapy during pandemic, you are in a way achieving a "more normal" immune system. Whether to pause immunosuppressive therapy is a very individual decision. In my daily practice, I look into the patient’s risk from their environment (need to commute to work versus staying home for remote work, etc.), their disease activity and their concerns about the pandemic. For mild patients that have high risk for contracting COVID-19 infection, I may consider holding off potent immunosuppressive therapy during the peak time of the pandemic. Most of my patients remain on their regimen. As I mentioned before, maintaining a normal immune system with immunosuppressive treatment is just as important when you think about infection risk. As I mentioned at the beginning, we know very little about COVID-19, but we've dealt with viral infections and coronavirus. Common cold viruses, for example are all forms of coronavirus (COVID-19 is simply a new virus in this family). It’s always helpful to apply strategies we’ve learned from dealing with other viruses. When our lupus patients who are on chronic steroids gets viral infections, we almost always continue with the prednisone dosage as long as it’s not a high dosage.
With COVID-19 infection, the initial phase is about the virus binding to cells to enter our body and start a replicating process. Antiviral treatment is important during this phase. However, the later phase is characterized by the body’s immune response aiming to fight off the virus, but which unfortunately can also target and damage tissues and organs. This inflammatory response to infection is a double-edged sword. Because of this inflammatory response, anti-inflammatory treatments such as steroids and biologics used in rheumatoid arthritis are being used in severe COVID-19 infection. In fact, we have been using steroids in critically ill patients with infections trying to limit the unwanted inflammatory damage.
Eliza: Now let's move on to doctor appointments. With New York in phase II reopening, when will be a safe time for me to see my doctors again, or should I do telehealth instead and wait until it's safe to be seen in the office again?
Dr. Yuan: OK, so seeing a doctor has two steps. First step is to leave your home and go to the doctor's office where transportation involved. There could be a risk for exposure there. The second part is your being in the office where you get into contact with other patients and staff.
For the transportation part, I’ve had patients ask a friend or family member to bring them in by a car, take buses and subways, or take access-a-ride. Public transportation is not very crowded these days and subways are quite clean since the pandemic started. Access-a-ride limits passenger number to only one so it’s pretty safe as well.
Hospitals and offices are cleaned thoroughly and all patients and visitors are screened routinely. We have taken measure to reduce patient volume in the office so social distancing can be observed. We have also tried to handle check-in online in order to reduce the time spent in the office. These days, having an in person visit in the office is quite safe. Lupus is a chronic disease that requires regular follow up and laboratory checks. Especially for lupus patients, we really rely on urine tests to know if there's any signs of kidney inflammation. That would be a very first sign because kidney inflammation is often asymptomatic. The importance of maintaining routine visits outweighs the risk of going to an office.
The key is to continue to take precautions, wear a mask and practice hand hygiene, observe social distancing. If you wear gloves, please make sure you don’t touch your face as gloves can provide a false sense of security.
Telemedicine/telehealth is another option for patients who don’t have to have in-person visit. Your doctor can tell you if it’s appropriate for your condition. Of course, your comfort level will influence your decision as well. For lupus patients, I find one main issue is that even though I can see them online, they still have to get the lab tests done at the local lab. For some patients, going to a local lab is still a lot more convenient than going to the office.
Eliza: We have about five minutes left. Let's move on to prevention. How do I strengthen my immune system? Will Vitamin D help me boost immunity against COVID? I’ve heard steaming can prevent or treat COVID, is it true?
Dr. Yuan: So the first key issue is our immune system. We have to keep in mind that there are two components of immune system especially relevant for lupus patients. One component is for self-defense so we can fight off invaders such as virus, bacteria, parasite, fungus, tumor cells. The other component is the inappropriate immune response against one’s own body, which is hyperactive in patients with autoimmune disease. To prevent COVID-19 infection, we need to strengthen the self-defense component of our immune system. We can achieve this by ensuring adequate sleep, manage stress level, taking supplements such as Vitamin D3. Suppressing the unwanted immune response against our own body is also critical so that our immune cells on the self-defense team do not get distracted and pulled to fight against our own body. This is achieved by controlling lupus activity. Vitamin D3 is considered an important supplement for maintaining normal immune system. You should take at least 2000 unit Vitamin D3. Getting a blood test for Vitamin D level is also helpful in guiding dosage choice. Vitamin C is also helpful. A lot of common cold prevention remedies contain both Vitamin D and zinc which should be a convenient choice.
Does sauna help prevent COVID-19 infection? Sauna is considered a good detox treatment. However it only raises body core temperature (37 degrees Celsius) very slightly and COVID-19 is resistant to 56 degrees Celsius for 30 minutes. So I don’t think sauna can prevent COVID-19 infection by raising core temperature of the body. It’s ok to use sauna for general health. With the COVID-19 pandemic, having access to private clean Sauna may be challenging.
Eliza: I think we'll have one last question. Are reusable cloth face covers as good as disposable surgical face masks for COVID?
Dr. Yuan: Surgical masks can block most of virus containing droplets. There was actually a study to look into the viral particle and how it's filtered by a surgical mask versus the cloth mask. When you compare the two, the cloth mask is 50% to 75% filtration efficiency as compared to surgical masks. The effectiveness of cloth mask depends on type of fabric. One advantage of surgical mask is that it’s mildly water resistant so does not get soiled easily
Eliza: Great! Time really flew by quickly. We will now wrap up the Q&A. Once again, thank you so much for being here today, Dr. Yuan.
Original presentation date: June 27, 2020.