Should You Get the COVID Vaccine If You Have RA?
A top rheumatologist explains what you need to know about the vaccine and your rheumatoid arthritis medications.
The COVID-19 vaccines are here, and they’re being distributed by the millions. Chances are, you know at least one person who has received one. But as welcome as these long-awaited shots are, they’re also stirring up some controversy—especially among those in the chronic community, who (understandably) have some questions. Like, are these vaccines safe for everyone? Will they interact with my medications? And, what are the side-effect risks?
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We hear you. And we’re taking your questions straight from our Facebook pages to the desks of top chronic disease experts as part of our original series #ChronicVaxFacts. To dive into the nitty gritty on rheumatoid arthritis (RA), we interviewed Mehrdad Matloubian, M.D., rheumatologist at University of California, San Francisco. He had a lot to say about the COVID vaccine for this group—especially how different RA medications might interact with the shot. Read on for more details.
HealthCentral: Could the COVID vaccine cause an RA flare?
Mehrdad Matloubian, M.D.: That’s a great question, and it is on the mind of all our patients with rheumatoid arthritis. Unfortunately, individuals with RA were not very well-represented in the clinical trials for the Pfizer and Moderna vaccines. So, we don’t have any direct data, but we can extrapolate from what we know about other vaccines. For example, there have been multiple studies done in people with RA showing that influenza vaccines do not lead to a flare of the disease. That’s really reassuring, with the caveat that the COVID vaccines use a different platform (mRNA).
The other thing for people with RA to keep in mind is that the disease can flare once in a while on its own. When it flares after vaccination, we don’t always know if it’s related to the vaccine or not. There isn’t a clear biological basis for us to say that these new COVID vaccines will result in a flare of rheumatoid arthritis.
HC: Is one vaccine better than another for people on RA medications?
Dr. Matloubian: This has not been studied, but the Pfizer and Moderna vaccines result in very similar immune responses and protection. Not only do they protect from infection, but when people who have gotten the vaccine get infected, they have not had as severe disease. And as far as I know, these vaccines have eliminated death from COVID, which is really a great measure of effectiveness. Both of them use a similar platform (both mRNA based) so there is no data to suggest that they will work differently in people with RA.
The single-dose Johnson & Johnson COVID vaccine (which uses viral vector technology) is not a live vaccine and should be safe in individuals with RA who are on immunosuppressive medications. The data on whether this vaccine was tested in individuals with RA is not available yet. But, based on our experience with other vaccines, such as the influenza vaccine, we do not expect people who receive the J&J vaccine to have more severe adverse reactions or a flare of their disease.
HC: Will the immunosuppressant drug I’m on to fight RA affect the efficacy of the COVID vaccine?
Dr. Matloubian: We don’t have any data specifically for the COVID vaccine—all the information we have is extrapolated from studies done with the influenza vaccine in people with RA. Based on that influenza vaccine data, we can divide immunosuppressant medications used for treatment of RA into four groups:
One group includes medications that do not affect vaccine responses. People on these medications should not worry about changing or holding them when they get the COVID vaccine. They include prednisone (less than 20mg per day), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), leflunomide (Arava), and TNF inhibitors Humira, Remicade, Enbrel, Simponi, and Cimzia. They also include other biologics such as the anti-IL-6 medications, tocilizumab (Actemra) and sarilumab (Kevzara), and oral medications such as azathioprine (Azasan). For this group, the American College of Rheumatology has recommended medications should not be withheld.
The second group includes a medication that does affect response to vaccination: abatacept (Orencia). The American College of Rheumatology has recommended that individuals who do the self-injection of abatacept to withhold their injection one week before their first dose of the COVID vaccine and one week after the first dose as, well. They don’t recommend holding it before or after the second dose of the vaccine (for folks getting the Pfizer or Moderna shot, that is). People on the monthly infusions of abatacept should get their first dose of the vaccine four weeks after the last infusion and delay their next infusion for another week.
HC: What are the other groups?
Dr. Matloubian: The third group includes people on rituximab (Rituxan) continuously. These individuals will not make neutralizing antibodies in response to their COVID vaccine, but they should still get it because the vaccine activates the T cell response in the immune system. So, people who are on rituximab can still get protection from the vaccine, and if they get infected, they are less likely to have severe disease or a bad outcome. [The American College of Rheumatology recommends that people on rituximab schedule their COVID vaccination to initiate four weeks before their next rituximab cycle, and then delay rituximab two to four weeks after their second vaccine dose.]
And the final group is a bit controversial and includes people on JAK inhibitors like Xeljanz (tofacitinib), Olumiant (baricitinib), and Rinvoq (upadacitinib) and people on methotrexate. For the JAK inhibitors, the American College of Rheumatology recommends that people should consider holding them for one week after their COVID vaccination. But the Crohn’s & Colitis Society does not recommend that IBD patients hold their JAK inhibitor medications, so there is some controversy there.
HC: What’s the deal with methotrexate?
Dr. Matloubian: Many individuals with RA are on different doses of methotrexate. The American College of Rheumatology has recommended that people on methotrexate who have stable disease should talk to their physician about whether they should hold their methotrexate for one week after their COVID vaccination. This should be a shared decision with your rheumatologist depending on how stable your disease is and your dose of methotrexate.
The idea behind all of this is to provide the best opportunity for people with RA to develop a strong immune response to the COVID vaccine without much available data. I personally am in the group of people who say, “Don’t let perfect be the enemy of the good.” I think people should get their vaccine as soon as possible, and that any immunity generated by the vaccine is better than having no immunity.
HC: Will the vaccine side effects be more severe because of my condition?
Dr. Matloubian: The general side effects that have been reported are fever and injection site reactions. Again, extrapolating results from studies of the influenza vaccine, it’s unlikely that people with RA will have more severe responses than the general population. But we still need to study this.
HC: People with autoimmune diseases were not included in the clinical trials. So, does that mean we are going to be the guinea pigs?
Dr. Matloubian: There is really no basis to be concerned that people with RA are going to have more a severe reaction or a disease flare with the new vaccines. Based on our limited experience, we haven’t seen a signal that people with RA will have worse outcomes.
HC: What are scientists doing to get data on vaccine safety for people with our condition?
Dr. Matloubian: There is tremendous interest in this, both nationally and globally. UCSF and multiple other institutes have ongoing studies to look at this question and inform our patients. So far, because of the limited vaccine distribution, the only people we can obtain data on are healthcare workers who have RA because they were first in line. We don’t have sufficient numbers of people to make any conclusions from that yet.
I would really encourage people, wherever they live, to talk to their doctor and see if there are similar studies where they are and whether they can participate. They will be helping other people with RA be informed about this and the more data we have, the better.
American College of Rheumatology COVID Vaccine Guidance: American College of Rheumatology. (2021.) “COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases.” rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf