COVID-19 Vaccination Strategies Suggested for Patients on Antirheumatic Immunosuppressive Therapy

By Marilynn Larkin

March 24, 2021

NEW YORK (Reuters Health) - UK experts propose evidence-based management strategies for rheumatology patients on immunosuppressive therapy, including delaying/postponing rituximab, as appropriate.

"The aim of this viewpoint article is to outline the existing data on the effect of antirheumatic therapy on vaccine responses in patients with inflammatory arthritis, and to formulate a possible pragmatic strategy for the management of therapies in these patients in the context of prospective COVID-19 vaccination," Dr. Paul Emery of the University of Leeds, UK and colleagues write in Rheumatology.

"But primarily we aim to facilitate an informed discussion between clinicians and patients in response to issues raised by these data."

"Patients on immunosuppressive therapy are being prioritized for vaccination, so management decisions will need to be made prior any additional COVID-19 data being available," they noted.

Dr. Emery told Reuters Health by email that the key findings, as noted in the paper, include:

- Existing work on vaccine response in disease-modifying antirheumatic drugs (DMARDs) is an imperfect surrogate for COVID-19 vaccine response.

- Methotrexate may impair humoral response; rituximab likely impairs humoral response for six months or longer.

- Consider risk-stratifying rituximab-treated patients and delaying/postponing therapy if appropriate before COVID-19 vaccination.

The researchers offered these specific therapeutic considerations with regard to COVID-19 vaccination:

- Avoid vaccination during a disease flare

- Taper steroid therapy to <10 mg prednisolone daily

- Consider withholding methotrexate monotherapy or combination therapy for two weeks post-vaccination; if two doses of vaccines are required, this likely would need to be done twice.

- Avoid vaccinating, ideally, for six months post-rituximab.

- If vaccination is imminent, consider delaying rituximab infusion if there is no risk of organ failure or disease flare; if a patient is unlikely to receive a vaccination for six months, expediting rituximab treatment could be considered.

- If there isn't enough time to change or amend DMARD/biologic treatment, then vaccinate and reassess the vaccine response at a later date.

Other findings from the team's literature review include:

- COVID-19 early registry data have shown anti-TNF therapy to be associated with decreased odds of hospitalization due to COVID-19.

- Conflicting data predominate for abatacept.

- JAK inhibition may be problematic in the context of the mRNA COVID-19 vaccines, which induce a strong type 1 interferon-driven immune response; theoretically, inhibition of this pathway could be associated with a diminished response.

Dr. Emery said the findings "probably" hold true across populations/demographics, and guidelines "possibly" should be amended to reflect the team's recommendations. Meanwhile, he added, the role of T/ B cells in COVID SARS-2 and outcomes is another critical area of research.

Rheumatologist Dr. Bruce Garner of NYU Langone Hospital-Brooklyn, New York City, told Reuters Health by email that he agrees with the recommendations.

"However, as the authors state, we do not have enough information to make definitive recommendations on the COVID vaccine and we are extrapolating based on other vaccines," he said. "There is no guarantee that these extrapolations are applicable to the COVID vaccine."

"That said," he noted, "the most important thing is to get the vaccine, to help both the individual and the public. Based on the recommendations recently published by the American College of Rheumatology, if my patients are well controlled on methotrexate, I do advise them to hold the next week's dose following the vaccine."

"However," he added, "if the patients are in danger of flaring, I advise them to continue their methotrexate."

SOURCE: https://bit.ly/31baXov Rheumatology, online March 12, 2021

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