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Should you offer COVID vaccination to patients with rheumatic diseases?: Here are the answers! - Dr. Rohini Handa

M3 India Newsdesk Jun 07, 2021

Last week, we presented a case study of a patient with rheumatic disease and we asked you questions on whether this patient could get the COVID-19 vaccine, and if she could, would she have to stop any existing medications in her ongoing treatment for RA. You gave us your answers which were evaluated by our expert, Dr. Rohini Handa. Here, he provides what the right response to each question is, and supporting points for each answer. 

Key practice points to consider

  1. COVID-19 vaccination should be offered to all patients with autoimmune rheumatic diseases (ARD) unless there are specific and cogent reasons to the contrary.
  2. The potential health benefits of vaccination outweigh the potential harms in people with ARDs.
  3. Patients with ARDs do not need any special pre-vaccination screening.
  4. No one particular vaccine is preferred over the other.
  5. In general, most anti-rheumatic drugs do not need to be stopped before vaccination. Continuing medication is recommended to prevent disease flares. Experts recommend withholding some DMARDs for a week post-vaccination as outlined in the table (included later in the article).
  6. Rituximab attenuates the vaccine response and the vaccine is best administered 4 to 5 months after the last dose of rituximab and at least a month before the next dose.
  7. Guidelines and recommendations change in light of emerging evidence and experience and should be considered as ‘living documents’ and not as immutable diktats.
  8. Physician judgment, in an individual case; it may override guidelines that are ‘recommendatory’ and not ‘binding’ in nature.
  9. Vaccination does not replace the need for COVID appropriate behaviour like masks, hand washing, and physical distancing.

The following are the answers to the case study questions

Question: Should Mrs. MK go ahead with vaccination for COVID 19?

The current guidelines recommend COVID-19 vaccination for all patients with Rheumatoid Arthritis (RA). Not only RA, but also patients with other autoimmune rheumatic diseases like systemic lupus erythematosus (SLE), vasculitis, Sjogren’s syndrome, etc. are advised vaccination.

Such an approach is supported by several professional bodies like the American College of Rheumatology (ACR) [1], Asia Pacific League of Associations for Rheumatology (APLAR) [2], European Alliance of Associations for Rheumatology (EULAR), Canadian Rheumatology Association [3], German Society for Rheumatology [4], and the Centers for Disease Control and Prevention (CDC) [5].

In fact, the ACR COVID-19 Vaccine Clinical Guidance Task Force recommends that patients with autoimmune rheumatic diseases (ARD) should be prioritised for vaccination before the non-prioritised general population of similar age and sex because ARD patients are at higher risk for hospitalised COVID-19, and face worse outcomes compared to the general population.

Question 2: Which vaccine should she opt for?

As of now, no one vaccine is prioritised over another, when it comes to recommending a vaccine for patients with autoimmune rheumatic diseases including RA. All approved COVID vaccines are non-live vaccines.

There is no head-to-head trials to inform the safety and efficacy of the various SARS-CoV- 2 vaccines in patients with ARDs. Since trials generally exclude patients with pre-existing conditions, the answer to this question is likely to come in due course from registry data and real-world experience. The CDC mentions that people with HIV and those with weakened immune systems due to other illnesses or medication may receive a COVID-19 vaccine. However, they should be aware of the limited safety data.

Question 3: Does she need CRP or any other tests before vaccination?

No tests are recommended before vaccination. CRP elevation in ARD is common due to immuno-inflammation. CRP testing does not help determine or preclude vaccine eligibility. Similarly, testing for IL-6, D-Dimer, ferritin, and antibodies to CoV (e.g., IgM and/or IgG antibodies to spike or nucleocapsid proteins) is not recommended pre- or post-vaccination.

Question 4: Should she stop any medicines before or after getting the jab?

It is expected that response to COVID-19 vaccination in ARD patients on immunosuppressive therapies may be blunted in magnitude and duration compared to the general population. However, this attenuation and its clinical implication have not been quantified. The general guidance on which drug should be withheld for how long is outlined in the table.

Question 5: Are there any special precautions for Mrs. MK?

No, beyond known allergies to vaccine components; there are no additional contraindications to COVID-19 vaccination in patients with ARD. Ideally, vaccination should be offered in the setting of well-controlled ARD.

Since this is not always practical or feasible, vaccination should be given irrespective of the activity and severity of RA. Routine use of aspirin, clopidogrel, anticoagulants, colchicine, etc. is not warranted in RA patients undergoing vaccination unless there is an underlying medical condition that requires the use of these drugs.

Question 6: Can she get the vaccine during her periods?

Yes, there is no data to suggest that vaccination should not be administered during menstruation. The coronavirus pandemic is a rapidly evolving field. The recommendations frequently get updated or modified keeping with the available data and unfolding evidence. Like other situations in medicine, the decision to vaccinate, too, should involve the patient as a part of shared decision making. Non-medical considerations like vaccine access and availability are not unimportant. Some untouched issues may be geography and time-specificity. Physician judgment, therefore, is irreplaceable!

Click here to see references

To read the first part of the case study, click here.


Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Rohini Handa is a Senior Consultant Rheumatologist from Delhi.

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