Newly updated COVID-19 vaccination guidance from the American College of Rheumatology offers detailed insight into how clinicians should proceed with use, timing, and prioritization of COVID-19 vaccines in patients with rheumatic and musculoskeletal diseases (RMDs).
“The task force advised health care providers to avoid being overly dogmatic in following these recommendations,” Jeffrey R. Curtis, MD, of the University of Alabama at Birmingham, and colleagues wrote. “The attempt to optimize vaccine response in relation to the use and timing of immunosuppressive medications should not compromise a willing patient’s ability to undergo vaccination in a timely manner and risk a missed vaccination opportunity.” The guidelines were published in Arthritis & Rheumatology.
To review the published literature and determine the safety and efficacy of the available COVID-19 vaccines for patients with RMDs, a task force made up of nine rheumatologists/immunologists, two infectious disease specialists, and two public health physicians was formed. The ACR COVID-19 Vaccine Guidance Task Force considered vaccine clinical trial data and overall COVID-19 risk and outcomes among RMD patients, along with the immunogenicity of other vaccines in patients on immunomodulatory therapies and the safety profile of non-COVID vaccines in RMD patients.
Using a 9-point numeric scoring system, the task force developed 74 draft guidance statements that were rated with a median score of 7, 8, or 9. Consensus was deemed strong for 16 of the statements and moderate for the remaining 58.
Of the general considerations related to COVID-19 vaccination, the only statement to achieve strong consensus called for the rheumatology health care provider to take responsibility for assessing their patients’ COVID-19 vaccination status. Other notable statements asserted that patients with autoimmune inflammatory rheumatic diseases (AIIRDs) are at higher risk for hospitalized COVID-19, compared with the general population, and should be prioritized for vaccination accordingly, even though a risk for disease flare or worsening exists and the expected vaccine response for patients on systemic immunomodulatory therapies is “likely to be blunted in its magnitude and duration.”
Takeaway advice
When asked about a top-line takeaway for rheumatologists, Dr. Curtis replied: “Make sure that your patients are getting vaccinated. Even though the vaccine in patients with compromised immune systems might not work quite as well and might not last quite as long, they still should get vaccinated. And vaccine hesitancy is a real thing.”
Citing unpublished survey data, he estimated that roughly 25% of people with rheumatic conditions remain unvaccinated, and more than half of them said they had no vaccination plans. “That’s a pretty important message when up to a quarter of your higher-risk people take a pass,” he said. “You’d expect it to be better in people at risk who are on steroids or immune medications. That’s something rheumatologists can help with the most.”
Regarding vaccine use, the task force strongly recommended that RMD patients be offered COVID-19 vaccinations consistent with the emergency use authorization’s current age restrictions and/or Food and Drug Administration approval. They also strongly recommended patients with AIIRDs receive the second dose of a multidose vaccine, even if the first dose led to nonserious adverse events, and that health care providers avoid ordering lab testing to assess COVID-19 immunity in vaccinated and unvaccinated patients.
The issues around testing for immunity are ample, Dr. Curtis said. For starters, “there are different antibodies, and one of them wouldn’t be expected to go up after vaccination.” And even if you are testing for the correct antibodies, “now I get a number. Is my number high enough that says that I’m protected? That’s what clinicians want, that’s what patients want. Unfortunately, we don’t have that test. There’s an antibody test; you can test against the spike protein and get a number, but whether that number has clinical relevance that says you’re protected, and how much, and for how long, we definitely don’t have that information. You could be falsely reassured or falsely alarmed by the results.”
This statement, he added, has been particularly divisive. “A bunch of rheumatologists have said to me: ‘Look, we’re doing this routinely for our patients.’ My rejoinder was: ‘That’s great to know; what’s the evidence base for what you’re doing there? Because I haven’t read that paper.’ I fully acknowledge that, in groups of patients on certain therapies, the antibody response seems somewhat lower. But doctors don’t treat groups of patients; we treat patients one at a time. And I want to know how to help the patient in front of me, and I want to know what to tell him or her if I get the results of an antibody test.”
Finally, the task force emphasized that all AIIRD patients should receive the COVID-19 vaccinations, exempting only those with life-threatening disease, and they stated no preference for one COVID-19 vaccine over the other.