Patients With Rheumatic Disease May Experience Flares After SARS-CoV-2 Vaccination

By Linda Carroll

June 25, 2021

(Reuters Health) - Among a group of New York patients with rheumatic diseases who received a SARS-CoV-2 vaccine, nearly one in six experienced disease flares after getting their shots, a new study finds.

A survey of more than 1,100 patients who had received at least one vaccine dose revealed that 14.9% experienced flares. Among the 654 who had received both doses of a Pfizer or Moderna vaccine, 113 (17%) flared, with 26 (23%) flaring only after the first dose, 48 (42.5%) flaring only after the second dose, and 37 (32.7%) flaring after both doses, according to the letter in Annals of the Rheumatic Diseases.

"This information is reassuring and can help inform vaccine decision-making for patients with SRDs (systemic rheumatic diseases)," the researchers, led by Dr. Medha Barbhaiya of the division of rheumatology at the Hospital for Special Surgery in New York, write in their report. "Although we did not collect laboratory studies, most SRD flares were described as 'typical', suggesting these symptoms are not vaccine's adverse effects being misreported as disease flares."

"However," the authors note, "when patients did flare, the majority of flares were reported as moderate to severe, with some lasting more than 3 weeks. Therefore, it will be important to follow these patients prospectively, as well as to perform analyses which incorporate potential confounders to identify predictors of SRD flares post-vaccination."

"Our study assessed self-reported disease flares, and was not designed to correlate disease flares with biological markers," said lead author Dr. Medha Barbhaiya of the Division of Rheumatology, Hospital for Special Surgery, in New York City. "Regardless, our data provides reassurance to physicians and patients that the rate of self-reported flares after COVID-19 vaccination by patients with systemic rheumatic diseases appears relatively low," Dr. Barbhaiya said in an email.

To explore whether the SARS-CoV02 vaccines might trigger flares, Dr. Barbhaiya and colleagues emailed a survey on March 5, 2021 to 3,545 outpatients with systemic rheumatic disease.

As of April 12, 2021, 1,483 patients responded, with 1,101 (74.2%) saying they had received at least one dose of a COVID-19 vaccine and reporting whether they had experienced flares. Just 16 (1.5%) had received the Johnson & Johnson vaccine and three (0.3%) received the AstraZeneca vaccine. The rest had received either the Pfizer (54.2%) or Moderna (43.9%) vaccines.

Among patients receiving either Pfizer or Moderna vaccines, 654 (59.4%) had received both doses.

A total of 202 SRD flares were reported by 165 patients (14.9%). A history of suspected/confirmed COVID-19 occurred in 7.9% with SRD flare and 6.7% without SRD flare. The mean age of patients reporting an SRD flare was 59.6 versus 61.0 years in the non-flare group.

Both the flare and non-flare groups used medications such as Benadryl, acetaminophen or NSAIDs for prevention and treatment of vaccine side effects.

Most SRD flares were described as moderate to severe, and appeared to be "typical" SRD flares. Symptoms reported during flares included joint pain, joint swelling, muscle aches and fatigue. While 27.7% of flares started one day after vaccination, 61.4% began after two to seven days and 10.9% occurred more than seven days post vaccination. Most SRD flares resolved within seven days of onset, but 26.2% lasted for 8-21 days and 8.9% for more than 21 days.

One thing you can't tell from this study is whether the patients temporarily discontinued their regular medications prior to vaccination, said Dr. Weiwei Chi, an assistant professor of medicine in the division of rheumatology at the Icahn School of Medicine at Mount Sinai in New York City.

"We have older studies that say, for example, that methotrexate can affect responses to flu vaccines," Dr. Chi said. "Some providers recommend holding methotrexate for a few weeks after vaccination to have the best protection."

Another issue with the study is that they seem to have lumped together several autoimmune diseases, Dr. Chi said. "When you lump everyone together it's really hard to draw conclusions."

In the end, this is a risk-benefit calculation, Dr. Chi said. "If you get COVID, it can be devastating and potentially fatal," she added. "In a sense, maybe the risk of a flare is worth it, when you're comparing the long-term consequences of a flare versus a severe case of COVID-19 or long-hauler symptoms."

"Overall, I think it's good to have this as a starting point," Dr. Chi said. "But I wouldn't take the results to mean that everyone needs to be really careful about vaccinating patients with autoimmune diseases."

SOURCE: Annals of the Rheumatic Diseases, online June 22, 2021.


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