Skip to main content
It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results.

Covid-19 HSE Clinical Guidance and Evidence

* Phone users, please scroll down to view content. Queries to: clinicaldesign@hse.ie

Immunisation Navigation

Specific Guidance for SARS-CoV-2 vaccination in Rheumatology patients

Specific Guidance for SARS-CoV-2 vaccination in Rheumatology patients (VCD19-001-001/12.02.2021)


  • Prof David Kane, National Clinical Programme for Rheumatology
  • Influenza and Pneumococcal vaccination are recommended for all rheumatology patients receiving immunotherapy and ALL patients being considered for SARS-CoV-2 vaccination should be strongly advised to have Influenza and Pneumococcal vaccinations. There is very good quality evidence of mortality reduction for patients who have influenza and pneumococcal vaccination.

 

Which (if any) groups of Rheumatology patients should be prioritized for SARS-CoV-2 vaccination?
  • In addition to existing known high risk groups, rheumatology patients on the following immunosuppressives should be prioritized for SARS-CoV-2 vaccination as they have a higher risk of hospitalization / death from COVID-19 while all other rheumatology patients on immunosuppressives will be offered the vaccine in due course.
  • High Risk*
    People taking Prednisolone at low to moderate doses (5mg/ day or greater but less than 10mg day) for 2 weeks or longer (or equivalent doses, see section 3*).
  • Very High risk*

    Prednisolone 40 mg/day* or greater for more than 1 week, or 10mg/day or greater for 2 weeks or longer.

    Or

    Cyclophosphamide, Rituximab, Alemtuzumab, Cladribine or Ocrelizumab in the last 6 months.

    Or

    People with autoimmune disease and with clinical immunosuppression manifest by recurrent infections and/or significant laboratory evidence of immunosuppression (severe neutropenia (ANC less than 0.5 x 109/L), lymphopenia & hypogammaglobulinaemia).”

* From HSE COVID-19: Interim Clinical Guidance: Immunosuppressant Therapy v5 updated 29th October 2020)
https://hse.drsteevenslibrary.ie/Covid19V2/pharmacy/medicinesmanagement

 

Recommendations for selection of SARS-CoV-2 vaccine by patient subgroup
  • There will be a number of SARS-CoV-2 vaccines with different mechanisms. Figure 1 (Nature 2020) outlines the mechanisms and Table 1 (Nature 2020) lists those currently in Phase 3 trials. The HSE has concluded agreements with 5 suppliers for the main vaccine designs (mRNA (Moderna, Pfizer), non-replicating vector vaccines (University of Oxford) and inactivated virus vaccines).
  • The Pfizer Biotech mRNA vaccine and Moderna mRNA vaccines which are currently licensed are not live vaccines and are recommended for patients on immunosuppressives.
  • Non-replicating vector vaccines (University of Oxford) are also deemed safe for patients on immunosuppressives.
  • There will be a number of SARS-CoV-2 vaccines with different mechanisms. Figure 1 (Nature 2020) outlines the mechanisms and Table 1 (Nature 2020) lists those currently in Phase 3 trials. The HSE has concluded agreements with 5 suppliers for the main vaccine designs (mRNA (Moderna, Pfizer), non-replicating vector vaccines (University of Oxford) and inactivated virus vaccines).

 

Recommendations for optimal timing of administration of SARS-COV-2 vaccine

(a) Patients on Methotrexate

  • Several studies have addressed the optimal timing of Influenza vaccination in rheumatology patients on low dose methotrexate and of Influenza and pneumococcal vaccination in rheumatology and oncology patients on Rituximab.
  • Patients on methotrexate who held their medication for 2 weeks after administration of influenza vaccination had a 4 fold increase in neutralizing antibody titres without a significant increased risk of disease flare compared to those who did not interrupt their MTX dosing. Longer periods of treatment interruption up to 4 weeks showed no increased benefit. It is not known if this translates into reduced influenza infection rates though the supposition that it does is logical based on what we know about vaccines and how they work.
  • For surgery it is already established practice to time surgery at the end of a biologic treatment cycle and restart at 10-14 days after to reduce peri-operative infection and minimize flare.
  • Therefore depending on your patient’s circumstances you may recommend that where possible patients on methotrexate should ideally schedule SARS-CoV-2 vaccination at the end of a treatment cycle and hold treatment for a maximum of 2 weeks if the treating clinician and patient agree on this strategy.
    There is no evidence that this strategy is of benefit with other DMARDs.

(b) Patients on Corticosteroids

  • It is not possible for patients on steroids to discontinue treatment for the purposes of SARS-CoV-2 vaccination - minimization of steroid dose under supervision of their doctor where possible may be of benefit to patients receiving the vaccine.

(c) Patients on Rituximab

  • Patients on rituximab have reduced numbers of B cells and a poorer antibody generation response to vaccines. It is recommended that patients should have SARS-CoV-2vaccination ideally 4 weeks before they receive rituximab treatment and if on treatment that it be scheduled for the end of a treatment cycle (e.g. 6 months after last dose for optimal effect).
  • In patients approaching a new treatment cycle in Q1 2021, clinicians should now consider identifying and pausing therapy if they can predict availability of vaccination for that patient. Clearly the main difficulty is predicting timing of vaccination for these patients.

 

References
  1. Furer V, Rondaan C, Heijstek MW et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2020; 79: 39-52
  2. Iacobucci G Covid-19: Risk of death more than doubled in people who also had flu, English data show. BMJ. 2020; 370m3720
  3. Hua C, Barnetche T, Combe B, Morel J. Effect of methotrexate, anti-tumor necrosis factor α, and rituximab on the immune response to influenza and pneumococcal vaccines in patients with rheumatoid arthritis: a systematic review and meta-analysis. Arthritis Care Res (Hoboken). 2014; 66: 1016-1026
  4. Park JK, Lee MA, Lee EY et al. Effect of methotrexate discontinuation on efficacy of seasonal influenza vaccination in patients with rheumatoid arthritis: a randomised clinical trial. Ann Rheum Dis. 2017; 76: 1559-1565
  5. Park JK, Lee YJ, Shin K et al. Impact of temporary methotrexate discontinuation for 2 weeks on immunogenicity of seasonal influenza vaccination in patients with rheumatoid arthritis: a randomised clinical trial. Ann Rheum Dis. 2018; 77: 898-904
  6. Park JK, Kim MJ, Choi Y, Winthrop K, Song YW, Lee EB. Effect of short-term methotrexate discontinuation on rheumatoid arthritis disease activity: post-hoc analysis of two randomized trials. Clin Rheumatol. 2020; 39: 375-379
  7. Gianfrancesco M, Hyrich KL, Al-Adely S et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. 2020; 79: 859-866

 Figure 1 – mechanisms of SARS-CoV-2 vaccines

fig 1 CD 201

 

Table 1 – Vaccines in Phase 3 trials 1/12/20

National Health Library & Knowledge Service. Health Service Executive. Dr. Steevens' Hospital, Dublin 8. Tel: 01-6352555/8. Email: hselibrary@hse.ie

Disclaimer