COVID-19 Vaccination in Patients with Inflammatory Arthritis and Related Autoimmune Diseases

Arthritis New Zealand-New Zealand Rheumatology Association position statement

Studies published to date have not shown that the use of oral disease-modifying anti-rheumatic drugs (DMARDs) and biological therapies for arthritis increase the risk of infection, hospitalization or mortality caused by the SARS-CoV-2 novel coronavirus.

Use of prednisone greater than 10 mg per day was, however, associated with an increased risk of hospitalization due to COVID-19 infection. 

Previous studies have shown that patients with poorly controlled inflammatory disease are at increased risk of infection.

It is therefore recommended that people with inflammatory arthritis continue to take DMARDs and biological therapies during the current pandemic, and try to minimize the use of corticosteroids such as prednisone. 

Research is currently underway to determine the safety and effectiveness of vaccines against the novel coronavirus in patients with rheumatoid arthritis. The results will not be available until later this year.

In the meantime, patients with inflammatory arthritis, including those taking oral DMARDs and biological therapies, have been receiving the COVID-19 vaccine in countries where this is available.

If inflammatory arthritis or its treatment are associated with adverse effects or poor immune responses to vaccines, we should get an early indication of this through the usual reporting channels. 

New Zealand is currently in the fortunate position of not having uncontrolled community transmission, and is able to roll out its vaccination program in a measured and cautious manner, responding to data from overseas as it becomes available.

The American College of Rheumatology (ACR) has released a COVID-19 vaccine clinical guidance, which recommends (among other things) that patients with auto-immune and inflammatory rheumatic disease should be given priority in the “vaccine queue”. It says that inflammatory arthritis is not a contraindication, i.e. not a reason to avoid vaccination. It says that the response to the vaccine may be somewhat less in this group and that there is a theoretical risk that disease may flare to some extent after vaccination. Any of the approved COVID-19 vaccines would be appropriate, and in the case of multi-dose vaccines, the follow-up dose(s) should be given. Household contacts should also be vaccinated.

The ACR recommends that methotrexate should be withheld for one week after each vaccine dose, for those with well-controlled disease. For patients on rituximab, it is recommended that the vaccine series is initiated approximately 4 weeks prior to the next scheduled rituximab cycle. These recommendations have been made to increase the effectiveness of the vaccine rather than due to concerns about safety.

It is important to note that none of the COVID-19 vaccines is 100% effective and that vaccination is not a substitute for public health measures currently in place, such as hand-washing, distancing, and isolation and testing when you have COVID-19 symptoms. 

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