COVID-19 in Autoimmune Rheumatic Diseases: Lessons Learned and Emerging Risk Stratification Approaches

The coronavirus disease (COVID-19) pandemic has posed unique challenges for individuals with autoimmune and autoinflammatory rheumatic diseases (AARDs), raising critical concerns about susceptibility, disease severity, treatment outcomes, and vaccine response. This mini-review draws on data from a national Greek cohort and global studies. It summarizes current evidence on disease course and risk stratification in AARD patients with COVID-19.Most patients experienced mild disease; however, those with advanced age, interstitial lung disease (ILD), and treatment with rituximab, mycophenolate mofetil, or corticosteroids demonstrated increased risk for hospitalization and mortality. In contrast, biologics targeting pro-inflammatory cytokines such as tumor necrosis factor (TNF) and interleukin 6 (IL-6) were not associated with worse outcomes and, in some analyses, correlated with reduced hospitalization rates. Notably, long-term sequelae, particularly persistent fatigue, emerged as a common burden, underscoring the overlap between post-viral symptoms and underlying autoimmune dysfunction. The serologic response to SARS-CoV-2 infection and vaccination was attenuated in some AARD subgroups, especially in patients receiving B-cell depleting therapies, emphasizing the need for tailored immunization and preventive strategies. Additionally, anosmia was inversely associated with hospitalization and may represent a biomarker of milder disease and more effective early immune responses. This review highlights key predictors of adverse outcomes and discusses implications for immunosuppression management, vaccination timing, and long-term care. As the pandemic evolves, identifying high-risk AARD patients and implementing precision prevention and treatment strategies remain vital priorities.