With input from Dr Monica Vasudev

The American College of Rheumatology: Guidance on COVID-19 vaccination for patients with rheumatic and musculoskeletal diseases (RMDs)

1. Decisions to be individualized, with regard to disease severity, comorbidities and treatments.
2. Patients with underlying diseases should be given priority for vaccination.
3. A patient with rheumatoid arthritis whose disease is controlled with hydroxychloroquine will probably have lesser risk than someone with severe vasculitis under treatment with intravenous cyclophosphamide or rituximab.
4. Vaccination should be done when the underlying disease is well controlled, if possible. However, a theoretical risk for disease flare or worsening after vaccination still exists.
5. No one vaccine preferred over another; patients should be given whatever is easily available.
6. No need to delay vaccination for patients on hydroxychloroquine, sulfasalazine, leflunomide, apremilast, or intravenous immune globulin.
7. For patients treated with rituximab, vaccination should be scheduled to be started 4 weeks prior to the next rituximab dose. This recommendation is based on a study that demonstrated differences in response to influenza vaccination on the basis of timing of rituximab dose.
8. Methotrexate should be withheld for a week after each dose of the vaccine. This recommendation was based on studies of pneumococcal and influenza vaccines.
9. A similar recommendation has been made for JAK inhibitors, owing to concern about the effects of this drug class on interferon signaling that may lead to decreased vaccine response.
10. Abatacept must be withheld for a week prior to and after the first dose of the vaccine. This recommendation was based on findings of a possible negative effect of this drug on the immunogenicity of the vaccine. Furthermore, the first dose tends to prime naive T cells; CTLA4 inhibits naive T cell priming; and abatacept is a CTLA4-Ig construct.
11. Intravenous cyclophosphamide is usually given at intervals of 2 or 4 weeks. The recommendation in this case was to give cyclophosphamide dosing a week after the vaccine doses, if possible.
12. It was recommended that rituximab be administered 2 to 4 weeks following the second vaccine dose if possible, but only if the disease is controlled enough to allow such a delay. This recommendation was based on immune responses to other vaccines, and it may not be possible to fully generalize this to the COVID-19 vaccine. (Medpage Today)

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA