COVID-19 and lupus: 83% of infected patients develop virus antibodies


More than 80% of patients with systemic lupus erythematosus (SLE) developed antibodies after confirmed bouts with COVID-19 even though many were on immunosuppressants, a new study reports. The findings, which appeared in The Lancet Rheumatology, suggest that SLE and its treatments usually won’t prevent antibody responses to the pandemic virus.

“Overall, our findings are reassuring that most patients with SLE who have had COVID-19 do mount an antibody response against the virus,” rheumatologist and study coauthor Ruth Fernandez-Ruiz, MD, a research fellow with New York University, said in an interview. “However, it is not known whether these antibody responses translate into enhanced protection or improved outcomes from reinfection. Therefore, the current recommendation for patients with autoimmune rheumatic diseases, including those with SLE, and no contraindications is to get vaccinated against COVID-19, regardless of previous COVID-19 status or the presence of SARS-CoV-2 antibodies suggestive of prior infection.”

Dr. Ruth Fernandez-Ruiz
Dr. Fernandez-Ruiz said she and her colleagues launched the study, the first of its kind, to understand whether patients with SLE could produce and maintain an antibody response to COVID-19. They also wanted to measure the burden of infection in their study population – patients with SLE in New York City, she added. “Many patients who had symptoms that could be consistent with COVID-19, or were asymptomatic but had sick contacts during the initial peak of the pandemic in New York, were not diagnosed at the time due to scarcity of available testing for those who did not require hospitalization.”

The researchers retrospectively tracked 329 patients with SLE, 51 (16%) of whom tested positive for COVID-19. The demographics of those who tested positive and negative were mostly the same: 94% women, 6% male, and median age of 43 years. Infected patients, however, were more likely to be Hispanic (47%) than the noninfected (24%).

The percentage of positive patients in this study is lower than 20%, the estimated prevalence of COVID-19 in New York City after the initial pandemic peak. The study authors wrote that “it is plausible that patients with SLE were counseled to exercise increased caution given their increased susceptibility to infections as a result of frequent immunosuppressant use and their underlying immune dysregulation.”

The current recommendation for patients with autoimmune rheumatic diseases, including those with SLE, and no contraindications is to get vaccinated against COVID-19, regardless of previous COVID-19 status or the presence of SARS-CoV-2 antibodies suggestive of prior infection.

Twenty-nine patients confirmed to have had the infection underwent COVID-19 antibody analysis, and 24 (83%) were confirmed to be antibody positive. The other 17% were negative for antibodies.

“We did not find patient-specific factors, including SLE medications, that were associated with a shorter or absent antibody response to COVID-19,” Dr. Fernandez-Ruiz said. “However, all 6 patients who required hospitalization for COVID-19 had sustained SARS-CoV-2 antibody positivity, whereas 6 (35%) of 17 patients who only required ambulatory care did not maintain an antibody response. Although our sample size was small and we cannot draw definitive conclusions, these findings may suggest an association between the severity of COVID-19 and the strength and/or durability of the antiviral antibody response.”

Most patients who were tested for as long as 40 weeks continued to be antibody positive. “These findings are reassuring that the antibody response to SARS-CoV-2 in most patients is durable and could suggest protection of these patients against reinfection and post vaccination,” Dr. Fernandez-Ruiz said.

What about vaccines?

“The findings of our study cannot be directly extrapolated to vaccine responses. However, it is reassuring that most patients with SLE and confirmed COVID-19 were able to mount a durable antibody response to the virus, even patients on immunosuppressing medications,” she said. “A recent study from Israel, which included 101 patients with SLE, showed that the Pfizer/BioNTech vaccine had an acceptable safety profile, without worsening disease activity post vaccination. However, this study and others have recently suggested that certain immunosuppressing medications used in SLE such as rituximab, methotrexate, mycophenolate mofetil, and systemic steroids may blunt the immune response to COVID-19 vaccines.”

Dr. Fernandez-Ruiz and associates noted several limitations of their study such as the small sample size and variations in disease manifestations, medications and antibody test timing. They wrote that “our study was underpowered to detect significant associations and draw fully valid conclusions about the reported findings,” and only unadjusted analyses were possible. In addition, “it remains unclear whether negative testing or loss of antibodies is explained by the presence of milder symptoms or is due to immunosuppressive medications.”

In an accompanying commentary, rheumatologist Martin Aringer, MD, of University Hospital Carl Gustav Carus and Dresden (Germany) University of Technology, wrote that the findings “seem to indicate that the humoral immune response of patients with SLE is more robust than perhaps thought,” and the findings about immunosuppressant treatments “should encourage patients with SLE to continue their prescribed therapy.

Still, he wrote, “it remains to be confirmed whether these SARS-CoV-2 antibodies are protective in patients with SLE. However, at present there are no convincing arguments that patients with SLE who recover from COVID-19 should differ from other patients who recover from COVID-19.”

Overall, Dr. Aringer added, “although we do not have the complete picture yet, these initial findings should be reassuring for patients with SLE.”

Moving forward, Dr. Fernandez-Ruiz said, “even in the presence of durable serologic response to the virus, it is still unclear to what degree and for how long prior COVID-19 protects against reinfection; hence, patients with SLE and no contraindications should be vaccinated.”

She added: “We are actively investigating how effective COVID-19 vaccines are in patients with SLE, in particular those on immunosuppressing medications and systemic steroids. We are also focused on assessing the safety of the available COVID-19 vaccines by looking at the frequency and severity of SLE flares post vaccination.”

Top image credit: Corona Borealis Studio/Shutterstock
Image credit: Wladimir Bulgar/Science Photo Library/Getty Images

No study funding was reported. Dr. Fernandez-Ruiz reported no disclosures. Some authors reported grant funding from Bloomberg Philanthropies, the National Institutes of Health, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases and various consulting and investigator relationships. Dr. Aringer reported no disclosures.