Guidance on the “Covid 19 vaccine”
Revised to version 2 on 20 Jan 2021
Changes: 1. NACI advice has changed . CRA position statement has changed (see bottom reference)
Revised to version 3 on 10 Feb 2021
Changes – clarification on rituximab advise. Update of links
Revised 8 March – new links added
15 March clarified that Astra Zeneca is non replicating and safe in immunosuppressed patients
Revision 15 April – Adds CRA new position statement as reference
Please refer to this page for our best current opinion on vaccination which we have written in an FAQ style. This is aimed ONLY at patients of our office. It will be reviewed when new information is available.
- We have had many calls about our stance on vaccination. About a quarter of the patients who talk to us express reservation about vaccination. Our stance is clear – we support vaccination of the population in a tiered fashion based on risk of a poor outcome from the virus.
- We are advising as best we can in line in line with the BSR and CRA advice. (Specifically, we do not fully agree with the initial (now changed) position of the National Advisory Committee on Immunization). We believe lack of data is not a reason to avoid vaccination, and that extrapolating our experience with other vaccines is sensible.
- This information is primarily aimed at patients with rheumatoid arthritis, psoriatic arthritis, and autoimmune diseases such as SLE, scleroderma, polymyalgia (i.e. patients likely to be on the medications listed below).
We are not in a position to advise on pregnancy and vaccination.
Which vaccines are available?
For the purpose of this page we consider these types of vaccine.
- mRNA vaccines which are processed by the immune system to trigger a protective immune response.
- Adenovirus vector vaccines – The Oxford/AstraZeneca vaccine contains a live adenovirus vector but is non-replicating so cannot cause infection and is therefore safe for people who are immunosuppressed.
By the time you are offered a vaccine we will have safety data from many hundreds of thousands of people to reassure us.
If you wish to learn more about the science of these vaccinations please search elsewhere.
Which of our patients would be considered clinically vulnerable to Covid 19?
Patients on one or more immunosuppressive medications which include:
- Prednisone (dose and time related)
- JAK inhibitors
- all anti-TNF drugs (eg etanercept, adalimumab, infliximab, golimumab, certolizumab and biosimilars of these);
- See note below.
Hydroxychloroquine or Sulfasalazine either alone or in combination are not considered immunosuppressive though if you are on sulfasalazine you may still be a patient in an at risk group.
Patients with other conditions including but not limited to:
- Age >70,
- Diabetes Mellitus,
- Pre-existing lung disease,
- Renal impairment,
- Heart Disease
Should I stop my medications to lower my risk of catching Covid?
No! The current best advice is that the risk of harm from stopping medications as “protection” against the virus is more harmful than good. Follow the public health advice in terms of shielding, hand washing, distancing, but do not stop medications.
If you have any active infection pause immunosuppressive drugs and seek advice from your doctor.
Prednisone should NOT be stopped suddenly and if you have any infection whilst on prednisone seek medical advice as this medication requires specific medical expertise.
Should patients continue their immunosuppressive therapy before and after vaccination?
We suggest in principle that where possible a patient holds their methotrexate for one week prior and following the vaccine as this may allow a more efficient response from your immune system. If you are worried about stopping methotrexate it is safe to continue it. You may get marginally less protection. Evidence supporting these decisions is limitied
This advice does NOT apply to any other medications and if you reach a point where vaccination is planned we will be pleased to offer advice on whether to pause medications or not.
What about rituximab?
Rituximab is special as it may have specific effects on the ability to develop immunising antibodies. We would recommend that if you have had rituximab within six months you call our office for advice before vaccination. However inprinciple we suggest do not get the vaccine within 3 months of rituximab confusing as your protective may be limited. If you have rituximab due in the next 2 months, again call us.
Will my medications prevent me from developing an adequate immune response?
We are not able to answer this, but our best thoughts are that you will still mount a meaningful response though possibly not as strong as a patient who is not on immunosuppressive drugs. It will still offer meaningful protection.
Will my disease flare after vaccination?
Whilst there are case reports of autoimmune diseases flaring after infections and vaccination, our current advice is that this very small risk is balanced by the individual and population benefits of vaccination. Vaccination is about protecting you, your loved ones, and the rest Ontario.
Do we know how long I will be protected for?
No – we have no reliable long-term data on the durability of response. Perhaps it is best to assume that the virus will act a little like flu, and annual vaccination may be needed. We cannot answer this. Nor do we know if having had a Covid 19 infection offers extra long-term protection. We will know more in another year of course.
How do I know the vaccine is safe…it was produced very quickly, and we have no long-term safety data?
We have decades of experience of vaccine use, and the currently available vaccines are based on far more robust long-term data than appears at first sight. Undoubtedly we have few long term data for these specific new vaccines, but we have very clear data of the tragedy of Covid 19 virus with ongoing potentially avoidable deaths. If we are to return to the life we had before Covid then vaccination of most of the population needs to be achieved.