Rheumatic patients urged to get vaccinated against COVID-19 without treatment interruption

Eligible patients with rheumatic diseases (PRDs) are strongly urged to get vaccinated against COVID-19, and the vaccine may be given while on immunomodulatory therapy, preferably during an inactive disease state, and without requiring testing for postvaccination antibody titres, according to recommendations from the Singapore Chapter of Rheumatologists.

Treatment with immunomodulatory drugs, except for rituximab, can be continued alongside vaccination. However, for patients commencing rituximab, the COVID-19 vaccine should be administered before treatment initiation, or a minimum of 6 months after the last dose and/or 4 weeks prior to the next dose of rituximab for patients in the middle of therapy. [Int J Rheum Dis 2021;doi:10.1111/1756-185X.14107]

The recommendations also highlight the importance of extending vaccinations to household contacts in order to protect vulnerable patients. With regard to the various SARS-CoV-2 vaccines, any of the approved vaccines may be used, with no particular preference.

Locally, the Pfizer-BioNTech and Moderna COVID-19 mRNA vaccines are approved by the Singapore Health Sciences Authority (HSA) via the Pandemic Special Access Route, with the Ministry of Health (MOH) Expert Committee on COVID-19 Vaccination (EC19V) having issued recommendations for their use. [tinyurl.com/yf6b3asj; tinyurl.com/yes9que3]

A core writing group, along with a task force panel (TFP), formulated the consensus recommendations based on the results of systematic literature reviews and Delphi method. The process incorporated all components of the Appraisal of Guidelines for Research & Evaluation (AGREE) instrument, apart from patient/allied health involvement, “for practicality.” 

“[T]he TFP were cognizant of the heightened risk of COVID-19 in our patients. Therefore, recommendations were formulated to aid practicing rheumatologists in their decision-making without being overly restrictive, while allowing individualized decision-making for each patient. These should take into account patient's disease status, ongoing treatment, risk profiles, preferences and local community transmission risk,” the members of the writing group pointed out.

It must be noted that the broad principles for COVID-19 vaccination in PRD in the current recommendations are in line what the American College of Rheumatology (ACR) has outlined, despite the unique pandemic situations—and, consequently, the risk-benefit balance of the vaccine—in Asia vs North America, they added. [tinyurl.com/yhrprmdp]

“The ACR recommended that COVID-19 vaccination should be timed according to the dosing of certain immunomodulatory treatments (rituximab, intravenous abatacept and intravenous cyclophosphamide) and that treatment with methotrexate, Janus kinase inhibitors, and abatacept should be temporarily interrupted prior to or after COVID-19 vaccination,” the writing group noted.

“However, as discussed, while there may be reduced vaccine immunogenicity in patients on these medications, sufficient protective efficacy has been demonstrated, thus forming the basis of our recommendation to vaccinate without treatment interruption or consideration for timing of doses,” they said. [Infect Chemother 2020;52:252-280; Rheumatology 2019;58:372; Swiss Med Wkly 2015;145:w14159]

To date, there are 79 candidate vaccines in clinical development, with a further 182 in preclinical development. More than 312 million vaccine doses have been administered worldwide since the rollout of vaccination campaigns in various regions in mid-December 2020. [tinyurl.com/yasnqdq2; tinyurl.com/yfgrro5a]

“It is important that governing institutions and healthcare providers continue to keep abreast of the latest evidence, so that recommendations can be reviewed and/or revised as new knowledge emerges. Particularly, data on safety and efficacy of vaccination in PRD are urgently needed to update recommendations in this vulnerable population,” according to the experts.