Infectious Disease

Vaccinate sufferers with autoimmune musculoskeletal inflammatory illness towards COVID-19

February 11, 2021

4 min read

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Disclosure:
Curtis reports on grants and personal fees from Abbvie, Amgen, Bristol Myers Squibb, Corrona, Eli Lilly and Co., Janssen, Myriad, Pfizer, Regeneron, Roche and UCB. Karp does not report any relevant financial information.

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Rheumatology patients with musculoskeletal, inflammatory, and autoimmune diseases should be vaccinated against COVID-19 according to the newly published recommendations of the American College of Rheumatology.

“Although there is limited data from large population-based studies, it appears that patients with autoimmune and inflammatory conditions are at greater risk of developing COVID-19 in the hospital and have poorer infection-related outcomes compared to the general population.” Jeffrey Curtis, MD, MS, MPH, from the University of Alabama at Birmingham and chair of the ACR COVID-19 Vaccine Clinical Guidance Task Force, a press release said.

“Ultimately, the task force agreed that in almost all cases it would be better to go ahead with vaccination and get at least a partial response than to postpone vaccination because the postponement offers no protection at all,” said Jeffrey Curtis, MD, MS, MPH, in a press release. Source: Adobe Stock

He added, “Because of this concern, the benefits of COVID-19 vaccination outweigh any small potential risks for new autoimmune reactions or disease outbreaks after vaccination.”

The new clinical guidelines, pending peer review, are designed to provide rheumatologists and other health professionals treating patients with rheumatic diseases with instructions on how to get the most out of COVID-19 vaccines. It also provides guidance on how to facilitate vaccination strategies for rheumatism patients. A draft summary of the guidelines and recommendations was approved by the ACR Board of Directors on February 8th.

Jeffrey Curtis

According to the ACR, the guidelines are a product of a multidisciplinary panel of nine rheumatologists, two infectious disease specialists and two public health experts. This task force met several times in December 2020 and January 2021 and proposed and reviewed clinical questions and the associated proposed guidelines for vaccines. Consensus building consisted of two rounds of asynchronous anonymous evaluations via email and two live webinars, including the full task force.

“There has been heated debate on a variety of subjects, such as the expected level of vaccine benefit for patients receiving therapies that significantly alter or suppress the immune system (such as high-dose steroids),” Curtis said in the press release.

“Ultimately, the task force agreed that in almost all cases it would be better to go ahead with vaccination and get at least a partial response than to postpone vaccination as postponement does not protect at all,” he added. “Given the lack of direct evidence for these vaccines in patients with rheumatology, the panel used general immunological principles observed with other vaccines to make recommendations to increase the likelihood of a favorable vaccine response.”

Navigating a changing landscape

The guidelines contained important considerations and reservations about vaccinating patients with high disease activity and those receiving immunosuppressive treatments. For example, the ACR recommends certain treatments such as methotrexate, Janus kinase inhibitors – such as baricitinib (Olumiant, Eli Lilly & Co.), tofacitinib (Xeljanz, Pfizer) and upadacitinib (Rinvoq, AbbVie) – and some biologics – abatacept (zu modify) to modify Orencia, Bristol Myers Squibb) and rituximab (Rituxan, Genentech) – which alter the immune system’s response in ways that could affect the vaccine response.

“For example, an RA patient with a well-controlled disease may benefit from holding a dose of methotrexate immediately after vaccination.” David Karp, MD, PhD, President of the ACR said in the press release. “For drugs with long dosing intervals like rituximab, in certain circumstances it may be beneficial to time the vaccine so that the last dose has been given in order to maximize the effectiveness of the vaccine. We encourage clinicians to study the charts provided in the executive summary for details on how to time different drugs for maximum success. “

David Karp

The panel based its recommendations on the use and timing of immunomodulatory drugs on evidence extrapolated from their immunological effects in relation to other vaccines and vaccine types. Therefore, these and other recommendations from the Task Force should be viewed as “conditional,” the press release said.

Also, given the uncertainty about when alternative vaccine types will be available, the task force focused on the two mRNA COVID-19 vaccines available in the U.S. at the time of their deliberation. The task force did not favor one vaccine over another and instead recommended that patients receive whatever vaccine was available to them.

“Since the effectiveness is roughly the same for both vaccines, we didn’t think it mattered which brand patients received,” Curtis said in the press release. “Realistically, many people don’t have a choice, as availability varies depending on location and region. Therefore, it was important to reassure providers and patients that this was not a factor to be considered when discussing vaccination. However, patients should use the same brand of vaccine for both injections. “

Instructions given. Available dates

The ACR warned that the recommendations should not and should not replace clinical judgment. Decisions regarding individual patients should be made through joint decisions with patients, taking into account their underlying health conditions, disease activity, current treatments, COVID-19 exposure risk, and geographic location, the press release said.

In addition, the ACR encouraged patients to continue to follow all public health guidelines regarding masks, social distancing, and other preventive measures even after vaccination.

The group also emphasized that changes to the guidelines are expected as additional safety and efficacy data become available.

“This is a very living document and the task force has plans to evaluate additional data in the coming weeks,” Curtis said in the press release. “We urgently need direct evidence from high quality research. To achieve this goal, we call on patients, providers and researchers to take action to mobilize and support the vital research effort to study the efficacy and safety of vaccines in rheumatic patients. “

The ACR will host a town hall with Task Force members on Tuesday, February 16 at 7:30 p.m. EST to discuss the guidelines and answer questions about the recommendations. Anyone wishing to participate must register online. Questions about the instructions can be submitted when registering.

“Our members have been inundated by their patients with questions and concerns about whether they should receive the vaccine,” Karp said in the press release. “We hope the guidelines will give them evidence-based confidence that their patients will benefit from vaccination and guidance on how to best incorporate it into their treatment plans to maximize the effectiveness of the vaccine.”

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