COVID-19 Vaccine Guidance for Patients with Autoimmune Diseases

We have received many questions regarding the use of COVID-19 vaccines in patients with autoimmune diseases on a wide range of advanced therapies such as biologics. The first thing to be aware of, is that the studies done for these vaccines did not include patients with autoimmune diseases or those on treatments that may suppress the immune system.  Current advice about being vaccinated, is based on expert opinion knowing this is a non-live vaccine. The general opinion of specialists in the field is that the benefit of getting a COVID-19 vaccine far outweighs the risk. 

What you should know:

  • The COVID-19 vaccines currently available are non-live. They cannot cause COVID-19 when given to any patient.
  • The effectiveness of any vaccine given to people who have an autoimmune condition may be less effective than the public. This does not prevent you from receiving the vaccine as having a lesser effect is much better than no effect at all.
  • Most treatments for autoimmune conditions do not blunt the benefit of vaccines.  However, we do know that methotrexate can reduce the effectiveness of the standard dose influenza vaccine.  We do not know how methotrexate may reduce the effectiveness of the COVID-19 vaccines.  Some healthcare providers may suggest holding 2 doses of methotrexate after receiving this vaccine in patients who are not having a flare of their inflammatory disease.
  • We know that the infused medication rituximab can significantly blunt vaccine benefit.  The suggestion would be to wait until 5 – 5.5 months after your last dose of rituximab and receive your COVID-19 vaccine.  Then receive the second dose of the COVID-19 vaccine (in the case of the Pfizer vaccine this is 3 weeks later).  Then wait an additional 2 weeks, at which time you can resume rituximab treatment.  
  • Prednisone can blunt the benefit of vaccines when used in doses of 20mg per day or higher for more than 14 days.  If you are weaning off prednisone, waiting until your dose is less than 20mg/day would be advised for greater benefit.
  • The COVID-19 vaccines by Pfizer and Moderna are called mRNA vaccines.  When mRNA-based treatments have been given in the past, there was a potential for an inflammatory response.  These vaccines have made modifications to prevent this, but you should know that a short-term flare of your condition could happen.  This means that if possible, it would be best to be vaccinated when you are in good control.
  • Other vaccines such as Shingrix for Herpes Zoster (shingles) protection, were released onto the Canadian market with no studies in this population.  As this vaccine was non-live and had great benefit, we widely gave it to patients knowing that it may be less effective in this group of people and that there could be a short-term flare of their inflammatory condition.  As time passed,  we collected data on this group of patients and found that they had a 90% benefit vs over 97% in the general public. This is still a fabulous response. We also learned that about 5% of people had a flare of their inflammatory condition for 1-2 weeks. 
  • We have learned that anyone receiving this vaccine can experience about 24-48 hours of certain symptoms which include: fatigue, headache, sore arm, low-grade fever, and general achiness. 
  • A few people receiving the vaccine who had a background of anaphylactic reactions to foods such as shellfish, had an anaphylactic reaction to the COVID-19 vaccine.  This does not prevent people with food allergies receiving the vaccine but does suggest that anyone who carries an EpiPen and has high sensitives to allergens should have an EpiPen on hand for the vaccine administration.
  • Anyone with an allergy to polyethylene glycol should not receive the Pfizer or Moderna vaccines.
  • The COVID-19 vaccines have not been studied when given at the same time as other vaccines.  It is suggested to wait 28 days after the final COVID-19 vaccine injection before giving any other vaccines. (live or non-live)  If you have recently received another vaccine, wait at least 2 weeks before getting the COVID-19 vaccine.

The Canadian Rheumatology Association and Canadian Association of Gastroenterology  have recently published their guidelines regarding patients with autoimmune diseases, both in support of vaccination.  They can be found on these links: 

CRA_Position_Statement_on_COVID_19_Vaccination_Dec2020.pdf (albertarheumatology.com)

CAG-COVID-19-Vaccines-in-IBD-Patients.pdf (cag-acg.org)

As part of these statements,  they refer to the National Advisory Committee on Immunization (NACI) which has also stated that the COVID-19 vaccine may be offered to these individuals if a risk assessment deems that the benefits outweigh the potential risks.  They suggest that obtaining informed consent from a patient,  includes discussion about the absence of evidence of the use of this vaccine in these populations,  and that there is a potential for lower vaccine response in those immunosuppressed. It is important to note that depending on the public health unit in your community, you may be asked to sign a consent to receive this vaccine or indicate you have had a discussion with your physician.  The pre-vaccination questionnaire that you will be given by the healthcare provider giving the vaccine, identifies immunosuppressive agents and/or autoimmune disease as factors that require consent.  

Please note the general guidance provided by this statement does not replace individual advice given to you by your specialist and healthcare team. 

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