ACR COVID-19 Vaccine Clinical Guidance
The American College of Rheumatology has issued COVID-19 vaccine guidelines specifically for patients with rheumatic and musculoskeletal diseases.
Summary of Recommendations
The American College of Rheumatology (ACR) has updated its vaccine clinical guidance for patients with rheumatic and musculoskeletal diseases (RMD). While each patient is unique, ACR’s COVID-19 Vaccine Clinical Guidance Task Force developed recommendations as a framework for addressing disease management within the context of vaccination against the SARS-CoV-2 virus.
The ACR guidance is not designed to replace the judgment of rheumatology care providers or overrule the values and preferences of their patients.
The task force members noted that the guidance is provided as part of a ‘living document,’ recognizing rapidly evolving evidence and the need for continuous monitoring of information about available mRNA vaccines and other types of COVID-19 vaccines in development. The guidance should be considered conditional or provisional. For additional details, click here.
- Autoimmune inflammatory rheumatic diseases (AIIRD) patients (e.g., RA, PsA, axSpA, gout, lupus, vasculitis) are at a higher risk for COVID-19 hospitalization and worse outcomes compared to the general population.
- Based on their COVID-19 risk, AIIRD patients should be a priority group for vaccine access before the general population of similar age and sex.
- For patients not yet vaccinated, either of the mRNA vaccines is recommended over the single dose J&J vaccine. There is no recommendation for one mRNA vaccine over another.
- Based on the evidence to date, there is no reason to expect that adverse effects from the vaccines will outweigh the benefits to RMD patients.
- There are no known additional contraindications to COVID-19 vaccines beyond known allergies to the vaccine’s ingredients.
- Rheumatology patients taking systemic immunosuppressive medications may experience a lesser response to a COVID-19 vaccine and the protection may not last as long as in the general population. Nevertheless, the vaccine is still very likely to provide meaningful protection, and RMD patients should be vaccinated.
- A third dose of Pfizer-BioNTech COVID-19 vaccine (age>= 12 years) or Moderna COVID-19 vaccine (age>=18 years) is recommended at least 28 days after the completion of the 2-dose mRNA vaccine series for patients receiving any immunosuppressive or immunomodulatory therapy, except for hydroxychloroquine.
- There is not enough data to recommend providing supplemental dose(s) of an mRNA vaccine to patients who already have received the single-dose J&J vaccine.
- Additional doses should be made to match the original mRNA vaccine received. However, if that is not feasible, a booster dose with the alternative mRNA vaccine is permitted.
- There is a theoretical risk that AIIRD patients may experience a disease flare after getting a COVID-19 vaccine, but the benefits of the vaccine’s protection outweigh the risks.
- Healthcare providers should not routinely order any lab testing (e.g., antibody tests for IgM and/or IgG to spike or nucleocapsid proteins) to assess immunity to COVID-19 post-vaccination, nor to assess the need for vaccination in a yet-unvaccinated person.
- It may be helpful to alter the timing of the following medications, in consultation with a rheumatologist, when following a COVID-19 vaccination schedule:
- methotrexate, mycophenolate, cyclophosphamide
- JAK inhibitors - baricitinib (Olumiant) tofacitinib (Xeljanz), upadacitinib (Rinvoq)
- abatacept (Orencia), rituximab (Rituxan, Ruxience, Truxim)
The purpose of doing so would be to maximize vaccine response; there were no safety concerns raised related to medication or vaccine timing.
Booster Doses and Timing
Except for glucocorticoids and anti-cytokine therapies (IL-17, IL-12/23, IL-23, IL-1R, IL-6R), hold all immunomodulatory or immunosuppressive medications for 1-2 weeks after booster vaccination, assuming disease activity allows.
Patients on rituximab or other anti-CD20 medications should discuss the optimal timing with their rheumatology provider before proceeding with booster vaccination.