Can COVID-19 vaccines be used in patients with autoimmune rheumatic diseases?

This study described the guidelines from the Canadian Rheumatology Association (CRA) on the use of COVID-19 vaccines in patients with autoimmune rheumatic diseases (ARDs). The CRA recommended the use of Canada-approved COVID-19 vaccines for patients with ARDs.

ARDs include chronic, inflammatory conditions such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and vasculitis. Patients with ARDs often require immune-suppressing medications to treat symptoms. Patients commonly experience additional illnesses and are at higher risk of infections, many of which are vaccine-preventable.

Messenger ribonucleic acid (mRNA) and viral vector vaccines are COVID-19 vaccines approved for use in Canada. BNT162b2 (Pfizer) and mRNA-1273 (ModernaTX) are approved mRNA vaccines. Those categorized as viral vector vaccines are ChAdOx1 (AstraZeneca) and Ad26.COV2.S (Johnson & Johnson).

Clinical trials for COVID-19 vaccines excluded patients with ARDs. There is, therefore, a direct lack of evidence supporting their use. Although initially erring on the side of caution, the National Advisory Committee on Immunization (NACI) now recommends the use of approved vaccines in individual patients with ARDs. Vaccine use in these patients is supported by other International Rheumatology groups.

The CRA members included rheumatologists, researchers, methodologists, vaccine experts and patients with ARD. A GRADE methodology was used to determine the certainty of evidence about the effects of COVID-19 vaccine administration to patients. It was also used for grading the direction and strength of the recommendation. Important measures were determined to assess the vaccine effects and evidence from clinical trials were summarized.

The panel considered that the potential benefits of currently approved COVID-19 vaccines outweigh the harms in most patients with ARDs. They recommended that patients with ARDs should not be denied vaccination and should not be required to take additional steps compared to people without ARDs.

Patients taking medications such as methotrexate (Trexall), mycophenolate mofetil (CellCept), tofacitinib (Xeljanz), and prednisone (Deltasone; 10 mg/day or more) may have lower vaccine responses. Abatacept (Orencia) and rituximab (Rituxan) may also be associated with lower vaccine protection. However, the panel considers that the benefits of the vaccines may still be big for all patients. 

The panel suggested that many patients with ARDs are older and have additional medical conditions which are associated with more severe COVID-19 disease. They also recommended that patients that receive vaccinations should still adhere to the protective measurements including isolation and hygienic measures to ensure protection from acquiring the infection.

The panel suggested that the side effects of the vaccines are minimal and consist mostly of local reactions. There is no data to suggest an increase in flares from the ARDs from the vaccines. 

The study provided a conditional recommendation for the use of Canada-approved COVID-19 vaccines in eligible patients with ARDs. Based on CRA guidelines, potential benefits outweighed potential harm for the majority of patients.