In this article, we will summarize the latest data available as of now, April 2021, concerning COVID-19 vaccination in patients with rheumatoid arthritis and other types of autoimmune rheumatic diseases. It is important to note that data are constantly being updated on that issue and we advise you to continually keep checking for the new updates that are released. The main source of data in this article comes from the latest recommendations of the American College of Rheumatology in addition to other published articles. 

*Important definitions: By autoimmune arthritis or autoimmune rheumatic diseases, we mean conditions like rheumatoid arthritis disease, psoriatic arthritis, ankylosing spondylitis disease, Still’s disease, systemic lupus, vasculitis and a long list of other diseases from this big family of diseases where the immune system fails to recognize some parts or tissues of the body and starts to attack them with antibodies the same way it attacks microbes that try to enter the body.

Question 1: Should I go for the vaccine?

Yes, you should.

In spite of the fact that our data from big studies, large population-based studies, on COVID-19 vaccination in patients with autoimmune arthritis are still limited, yet, latest evidence tells us that patients with autoimmune rheumatic diseases are at a relatively higher risk to develop a COVID-19 infection of the type that requires hospitalization compared to the general population. This also puts them at risk for worse outcomes if they get the infection. For that reason, even if a COVID-19 vaccine might result in some autoimmune reaction or flare of the disease, yet, the benefits of the COVID-19 vaccine still far outweigh those risks.

Even the family members or those in contact with a patient with rheumatoid arthritis disease are strongly advised to go for the vaccine when it is available to them to help limit any chances that the rheumatoid patient might get the infection even after vaccination.

 

Question 2: If my disease is active now, is it still okay for me to go for the vaccine?

Yes, it is still ok. 

The best time for any vaccine in general for a patient with an autoimmune arthritis is when the disease is well-controlled with medications.

But, given the urgency of protection against COVID-19, it is strongly advisable to go for the vaccine as soon as possible regardless of how active or how severe your disease is. The only exception here are patients with a life-threatening illness, a patient in the ICU for example.

 

Question 3: If I go for the vaccine, are there any changes needed for the use or timing of my rheumatoid medications?

Yes, there might be some modifications needed depending on which medication you are using.

At the end of this article, you will find a list of the names of the different disease modifying anti-rheumatic drugs (DMARDs) that you might be using whether non-biologic or biologic with the needed modifications needed for their use and timing when you are going for the vaccine.  

Question 4: Given the fact that vaccines work by stimulating the immune system, and given the fact that my immune system is already hyperactive (that’s why it caused my autoimmune arthritis), will I be at risk of side effects if I go for the vaccine?

We are not sure if you are at a particular extra risk compared to the general population

There is a theoretical risk that you might get a flare of your disease or you might get an autoimmune reaction. However, in all cases, still, the benefit of a COVID-19 vaccine in a patient with rheumatoid arthritis disease far outweighs a theoretical or even an actual risk of a reaction to the vaccine.

 

Question 5: Given the fact that I am using medications that suppress the immune system to control my autoimmune arthritis, will I still benefit from the vaccine? Will it still stimulate my immune system to make a protection against the virus?

Yes, you will still benefit from the vaccine. 

If you are receiving immunomodulatory and immunosuppressive disease modifying anti-rheumatic drugs (DMARDs) to control the activity of rheumatoid arthritis, your immune response to the vaccine might be blunted in magnitude to some extent. This is related to the particular DMARD that you are using whether a non-biologic DMARD or a biologic DMARD and is also proportional to the dose of the DMARD that you are using. Yet, and in spite of that limiting factor, still, going for the vaccine and getting even a partial response is by all means better than not going for the vaccine and not getting any response at all. Partial protection against a potentially very troublesome infection is better than no protection at all.

Question 6: Which vaccine to use?

The vaccine that is available by your health authorities

If you are going for the first dose of one of the COVID-19 vaccines, the answer is: No specific type is recommended here (yet at least); use the vaccine that is available through the health authorities in your country. There are no head-to-head studies that give priority to one vaccine over the other in terms of safety and efficacy.

Question 7: Which vaccine to use in the second dose?

A very specific type

Now if you have already received a first dose of one of the multi-dose vaccines and you are going for the second dose, the answer here is: use a very specific type; use the same type you used in the first dose. Don’t shift to another brand. An exception here is if some serious side effect happened with the first dose of a vaccine. In that case, your doctor will tell you what to do in your particular situation.

Question 8: If I get the vaccine, do I need to still follow the public health guidelines to prevent COVID infection?

Yes, you still need to do that

You still need to follow all of them; you need to still wear a mask and still do physical distancing.

Question 9: Is there an adverse interaction between the vaccine and my medications?

There are no adverse medical symptoms that you might get because of an interaction between the vaccine and rheumatoid medications

Patients usually ask this particular question because doctors recommend changes in the use or timing of rheumatoid medications when patients are going for the vaccine. If your concern here is vaccine interaction with your medications, there are no issues here with an adverse interaction. The recommendations for the use and timing are all about body response to vaccine. They are all about protecting your vaccine and the response of your body to the vaccine from the immunity-suppressing medication you are using. We are trying to optimize your response to the vaccine. We are trying to limit the effect of your medication on the efficacy of the vaccine. That’s all.

 

Question 10: So, what are the guidelines that are related to the use and to the timing of the vaccine and my medications?

For patients who are using one of the following medications:

Plaquenil (other names: Hydroquine, Quenil, Arthrosave), Salasopyrin, Cortisone (prednisolone whether in doses less than or more than 20mg), Arava (other names: Avara, Arthfree, Apetoid, Lefora), Enbrel, Simponi, Cimzia, Humira, Remicade, Amgevita, Actemra, Kevzara, Otezla, Intravenous immunoglobulins, Cellcept, Imuran, Azaprine, Oral Endoxan, Kineret, Ilaris, Cosentyx, Taltz, Stelara, Tremfya, Benlysta, Sandimmune, Neoral, we advise them to go for the vaccination without the need for modifications to either the medication they are using or the vaccination timing.

 

For patients who are on methotrexate, we hold methotrexate for 1 week after the vaccine shot provided the disease is under control as a well-controlled disease will make that temporary interruption of the medication possible without problem. If not, if the disease is not under control, we don’t need to do any modifications.

For patients on Xeljanz or Olumiant or Rinvoq, we advise patients to hold the medication for 1 week after the vaccine shot regardless of whether their disease is under control or not.

For patients on SC Orencia, what we do is that we hold SC abatacept dose 1 week before and 1 week after the first COVID-19 vaccine shot only. There is no need for another interruption around the second vaccine shot.

For patients on IV Orencia, we make the first vaccine shot 4 weeks after the Orencia infusion. This was actually supposed to be the time for the next Orencia infusion. At the same time, we postpone this next Orencia infusion for 1 week so that the gap between those 2 Orencia infusion becomes 5 weeks instead of the regular 4 weeks. We don’t do any adjustment of medication dose for the second shot of the vaccine.

For patients on IV Endoxan: we make sure the IV dose will be around 1 week after each vaccine shot if possible.

For patients on Mabthera: If possible, if for example the patient is following strict preventive measures and so his/her chance of getting the infection is relatively lower, what we do is make the first vaccine shot four weeks before the next cycle of Mabthera. When the vaccine shots have been completed, we try to delay the next dose of Mabthera for 2 to 4 weeks if possible.

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Those were the ten most important questions that patients with rheumatoid arthritis ask me about COVID-19 vaccine. There is one extra question that I was asked 3 times only yesterday. The question is

Did you Dr. Hatem, receive the vaccine?

Yes, I did.

I had my first dose on the 7th of March 2021 at the faculty of medicine at Cairo university in that office on the second floor and I go for my second dose on the 6th of June 2021.

 

One last advice...

The data on COVID-19 and COVID-19 vaccination in patients with rheumatoid arthritis disease and autoimmune arthritis are constantly being revised and updated as we get more data from current studies. make sure you follow any updates we publish on that issue...

 

References:

COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases Developed by the ACR COVID-19 Vaccine Clinical Guidance Task Force. A draft summary approved by the ACR Board of Directors on February 8, 2021, and updated on March 4, 2021.

 

Tsvetelina Velikova 1, Tsvetoslav Georgiev. SARS-CoV-2 vaccines and autoimmune diseases amidst the COVID-19 crisis. Review Rheumatol Int. 2021 Mar;41(3):509-518.

Haug N, Geyrhofer L, Londei A, Dervic E, Desvars-Larrive A, Loreto V, Pinior B, Thurner S, Klimek P. Ranking the effectiveness of worldwide COVID-19 government interventions. Nat Hum Behav. 2020;4(12):1303–1312. doi: 10.1038/s41562-020-01009-0. 

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This post was prepared and published by  Dr. Hatem Eleishi. Dr. Hatem Eleishi is a professor of rheumatology at Cairo university (Egypt) and is especially dedicated to supporting arthritis patients with online educational videos and articles about arthritis causes and treatment. He also runs a rheumatology clinic in Cairo and a center for online medical consultations that, in addition to providing online rheumatology consultations, also provides online medical consultations in several different medical specialties by expert consultants from Egypt, Canada and the United States.

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