Rheumatoid Arthritis and the Flu

Some people regard the flu as a yearly aggravation. For many others, it is much more than that and presents a real danger to their health. According to the Centers for Disease Control and Prevention (CDC), each year between 5% and 20% of Americans get the flu, about 310,000 are hospitalized because of it, and tens of thousands die from flu-related causes. The flu does not affect all people equally. Many factors can raise a person’s risk of contracting the flu and of developing more severe symptoms from it. Among the factors that increase flu risk are the inflammatory types of arthritis, such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), and some drugs commonly used to treat these conditions. For this reason, people with inflammatory arthritis need to take extra precautions during flu season. This article explores the risks and complications associated with rheumatoid arthritis and the flu.

What is the flu?

The flu — short for influenza — is brought on by a virus. As discussed below, there are different types of influenza viruses, but all bring on a similar slate of symptoms, which can be mild or severe and may go away quickly or linger. Possible flu symptoms include coughing, a sore throat, runny or stuffy nose, headache, body aches, fever, chills, diarrhea, and vomiting.

There are three types of influenza viruses: A, B, and C. Human influenza A and B viruses are the ones behind the seasonal flu outbreaks that occur almost every winter in the United States. The C virus is a milder version that does not cause epidemics.

The A virus is divided into subtypes by the existence of certain proteins on its surface. The two main subtypes are known as the H1N1 and H3N2 viruses. (Influenza B viruses are not divided up by subtypes.) Each year, a seasonal vaccine is created to protect against a combination of influenza A viruses and the influenza B virus. When deciding which flu strains the seasonal vaccine will target, researchers consider many factors, including the types of flu that are prevalent in the southern hemisphere, which has its flu season during our summer.

In 2009, a never-before-seen strain of the influenza A H1N1 virus was reported. It was different from the more established strains and was therefore called “novel” 2009 H1N1 strain — or, more popularly, “swine flu.”

“Most of the time we see flu with genes from birds, pigs or human viruses,” said Daniel E. Furst, MD, Carl M. Pearson Professor of Rheumatology at the University of California at Los Angeles. “What the novel H1N1 virus did last year was take genes from birds, swine and humans, tossing them all together. This triple assortment was the real new issue.”

Rheumatoid arthritis and the flu: Risk factors & complications

Even healthy people can get the seasonal flu and develop serious problems from it. However, research has shown that some people are more likely than others to have major complications from the flu. The following people are at increased risk:

  • People older than 65
  • People of any age with chronic medical conditions such as asthma, diabetes, heart disease, or inflammatory types of arthritis
  • People with weakened immune systems from conditions such as HIV/AIDS and cancer or from immune-suppressing medicines
  • Pregnant women

The types of arthritis that raise the risk for serious flu complications are known as inflammatory or autoimmune types of arthritis. These include RA, SLE, and psoriatic arthritis — but not osteoarthritis (OA), the most common type. There are two reasons that people with inflammatory arthritis are at increased risk for the flu. First, emerging evidence suggests that the inflammatory arthritis itself is a risk factor because of its effect on the immune system. In people with inflammatory arthritis, the immune system turns against the body and attacks the joints. “While we don’t have specific data on the risks for influenza in RA patients, we do know that persons with RA are more prone to all types of infection, including respiratory infections,” said Jennifer Hootman, PhD, an epidemiologist with the Arthritis Program at the Centers for Disease Control and Prevention (CDC) in Atlanta. She noted that in addition to being more likely to contract the flu, people with RA or another cause of weakened immunity may get sicker or be more prone to complications when they get the flu.

The second risk factor for people with inflammatory arthritis is the medicine they take to control their condition. Because inflammatory types of arthritis are caused by a misdirected immune system, many of the medicines used to treat them work by suppressing the immune system, which increases the risk of infections. These medicines are known as disease-modifying antirheumatic drugs (DMARDs) and include the newer class of biologic drugs. The traditional DMARDs used to treat inflammatory arthritis include azathioprine (brand name Azasan, Imuran), cyclophosphamide, cyclosporine (Neoral, Gengraf, Sandimmune),hydroxychloroquine sulfate (Plaquenil), leflunomide (Arava), methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo), mycophenolate mofetil (CellCept), sulfasalazine (Azulfidine, Sulfazine), apremilast (Otezla) and tofacitinib (Xeljanz). Biologics that treat arthritis include abatacept (Orencia), adalimumab (Humira), adalimumab-atto (Amjevita), anakinra (Kineret), certolizumab pegol (Cimzia), etanercept (Enbrel), etanercept-szzs (Erelzi), golimumab (Simponi, Simponi Aria), infliximab (Remicade), infliximab-dyyb (Inflectra), rituximab (Rituxan) and tocilizumab (Actemra). In addition, powerful anti-inflammatory drugs called corticosteroids, which include prednisone, methylprednisolone (Medrol) and hydrocortisone, can also raise flu risk.

Vaccines and inflammatory arthritis

Getting vaccinated is the most important thing you can do to avoid the flu and its complications. In the 1790s, English physician Edward Jenner tested a theory that exposing people to a less virulent version of a disease could trigger the production of antibodies that would protect them from the full-blown disease. (Antibodies are proteins produced by the body to fight off harmful substances.) The theory was proved correct when Jenner inoculated people with cowpox to protect them against its close cousin smallpox.

The injected flu vaccine — the well-known “flu shot” — works in much the same way as Jenner’s smallpox vaccine. Called an inactivated vaccine, it contains killed versions of a specific flu strain. Although the virus is dead, it still stimulates the body’s immune system to produce virus-fighting antibodies. If a person is later exposed to the actual virus, the antibodies are standing by to stop it. For people with inflammatory arthritis, the flu shot is the recommended way to get vaccinated.

Another kind of flu vaccine, known as a live attenuated vaccine, uses a live virus that has been weakened but not killed. In most people, the body easily kills off the weakened virus, and in the process makes antibodies that can then attack a full-blown virus if necessary. The live attenuated vaccine for flu is given by nasal spray and should never be used by people with inflammatory arthritis, whose immune systems may not be strong enough to fight off the live virus.

“While not 100 percent effective, [the flu shot] does greatly reduce the likelihood you will get the disease,” said John J. Cush, MD, Director of Clinical Rheumatology at the Baylor Research Institute in Dallas. “Even if you still get the flu, it seems to make it milder.” There is no way for a person to get the flu from a flu shot, Dr. Cush noted. However, the vaccine can take up to four weeks to fully protect against the flu. If a person is exposed to the flu virus in the meantime, an infection is more likely to occur.

In 2006, a study published in the journal Annals of the Rheumatic Diseases raised some concern about the effectiveness of flu vaccines in people with RA. In the study, researchers from Israel found that people with RA had less of a response to flu shots than people in the control group, who did not have RA. “These results are a little misleading,” said Dr. Furst. “When you look at the number of antibodies in their blood, people with RA tend to have fewer than the controls. However, they still produce more than enough antibodies to be protected. So you get a little less response, but it is still enough to protect you.”

Both Dr. Furst and Dr. Cush stressed that people with inflammatory arthritis who are taking drugs that suppress their immune system should get only the flu shot and not the nasal spray. When a live virus is given to a person whose immune system is compromised by disease or medicine, there is a risk of widespread infection.

Getting a flu shot is usually straightforward. In late summer or early fall, ask your family physician or rheumatologist if he or she will be offering the seasonal flu shot. You might also look for articles in newspapers and magazines or on the radio or television giving information on where the vaccines will be available. Depending on your specific location, drug and grocery stores may sponsor clinics that administer the vaccines, or the vaccines may be available through a local hospital or visiting nurse service at low or even no cost.

It is important to get a yearly flu shot because different strains of influenza A and B go around every year. For example, the H1N1 strain was included in the 2009 seasonal flu vaccine.

Some people should not be vaccinated without first consulting a physician. They include the following:

  • People who have a severe allergy to chicken eggs
  • People who have had a severe reaction to a flu vaccination in the past
  • People who developed Guillain-Barré syndrome (a rare condition in which the immune system attacks the body’s nerves) within six weeks of getting a previous flu shot
  • Children younger than six months
  • People who have a moderate or severe illness (they should wait until they recover)

If you have questions about whether you should get the flu vaccine, talk to your health-care provider.

Despite the importance of getting vaccinated for the flu, studies show that many people with RA do not follow through. Two studies presented at the American College of Rheumatology’s Annual Scientific Meeting in 2007 found that only around half of adults with arthritis were properly vaccinated. “Unless you are allergic to eggs or have had a bad reaction to the shots in the past, everyone with RA should get a flu shot every year,” said Dr. Hootman. “This is the single best way to prevent the flu.”

Avoiding the flu

Even if you have been vaccinated, there is still a risk that you will catch the flu. You still need to take some precautions during flu season.

Flu viruses are spread from one person to the next through coughing or sneezing. You can also get it by touching something with the flu virus on it and then touching your mouth, nose or eyes. “Washing your hands frequently with soap and water or an alcohol-based cleanser is an important way to lessen the chances you will get the flu or pass it on if you have it,” said Dr. Hootman. “Avoid touching your eyes, nose or mouth. To the extent possible, stay away from others who are sick.”

Of course, that doesn’t mean you can’t leave the house. “I do not recommend to patients that they stay home unless they are sick,” said Dr. Cush. “You can get the same bugs from family members as you get from strangers at the grocery store. It is foolish to hide at home when the suggested hygiene measures work so well.” Dr. Cush also discourages the use of surgical masks when in public. Those generally available in drug stores haven’t been shown to be protective.

If you do contract the flu, avoid spreading the virus yourself by covering your mouth and nose with a tissue whenever you cough or sneeze. Then throw the tissue in the trash and wash your hands. Bear in mind that adults with the flu are able to infect others at least one day before symptoms develop and for five to seven days afterward. That means that you may be able to pass along the flu before you know you are sick and after you start feeling better.

If someone in your household has the flu, it is possible to avoid getting it yourself. Wash bed sheets and towels using laundry detergent and tumble dry on a hot setting. Don’t grab the dirty linens and hug them to your body before cleaning; this can transfer flu viruses to your clothes. And always remember to wash your hands with soap and water right after handling dirty laundry.

As with linens, eating utensils and dishes used by people with the flu can be cleaned in a normal manner using standard detergents and water heat settings. Again, make sure you thoroughly wash your hands immediately after washing dishes.

Other suggestions for flu avoidance include the following:

  • Maintain good health by eating nutritious food, drinking a lot of water, getting enough sleep and exercising regularly.
  • Avoid being in crowded and poorly ventilated places for extended periods.
  • Improve airflow in your living space by opening windows.

The health professionals interviewed for this article stressed that it is a good idea to follow these suggestions throughout the year. Doing so can help lower the chances you will get other transmissible diseases such as colds or bacterial infections. In addition, it is easier to remember to follow these guidelines during flu season if they are a habit all year long.

Treating the flu

People with inflammatory arthritis who are feeling the early symptoms of the flu should get to their health-care provider immediately. Although antiviral medicines haven’t been shown to prevent influenza infections, they may make the illness milder, shorten the time of sickness and prevent the more serious complications of the flu. These drugs, which include zanamivir (Relenza), oseltamivir (Tamiflu) and peramivir (Rapivab) work best if they are started within two days of when flu symptoms first appear. According to the CDC, people with conditions that compromise the immune system, including RA, should get high priority for receiving antiviral drugs.

Other treatment options are less promising. “There are certainly a lot of dietary supplements and herbal concoctions being sold on the Internet and elsewhere that are said to prevent or treat the flu,” said Adriane Fugh-Berman, MD, Associate Professor in the Department of Physiology and Biophysics at the Georgetown University School of Medicine in Washington, DC. “There is no good evidence that they work.”

Echinacea is one herb that, while shown not to prevent colds, may slightly decrease the duration of cold symptoms (the scientific evidence on this is mixed). However, it has not been studied in the flu. In addition, it has compounds that may stimulate the immune system. Because of this, Dr. Fugh-Berman warns that people with RA should not take echinacea.

It has been established that deficiencies in zinc and vitamin A have an impact on immune function. However, in the United States, actual deficiencies in either substance are very rare. In addition, both can have side effects if taken in too-high doses.

Other popular vitamins or supplements that are sometimes said to have an impact on the flu include elderberry extracts and vitamin C. While Dr. Fugh-Berman has seen no reliable research indicating that these are effective, she does say that both are harmless if taken in recommended doses.

Both the Food and Drug Administration (FDA) and the Federal Trade Commission (FTC) warn consumers to be very cautious about products claiming to prevent, treat or cure the flu. They say you should be especially careful about pills, air filtration devices and cleaning agents that claim to kill the virus. For more information about fraudulent products, go to the FDA website.

The consensus of the doctors interviewed for this article is that dietary supplements have not been shown to prevent the flu or lessen its symptoms and that they should not be used in place of regular medical care. If you have flu symptoms, don’t postpone going to see a doctor while you see if these treatments work. If you do decide to take a supplement, discuss it with your doctor first to make sure that it doesn’t have any side effects or interact with the drugs you are taking.

The take-home message is that people with RA or other types of inflammatory arthritis need to be especially vigilant during flu season. “Every person with RA needs to know that they are higher risk for both flu and bad outcomes [from flu],” said Dr. Cush. “That is why it is important to take the suggested measures to ward it off as best they can.”

Kurt Ullman has been a medical writer for more than 25 years. He is based in Indiana.

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