Advice about the Covid vaccine

Guidance on the “Covid 19 vaccine”

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.

Notes:

  1. We have had many calls about our stance on vaccination. Over half 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.
  2. We are advising in line with the BSR advice. We believe lack of data is not a reason to avoid vaccination, and that extrapolating our experience with other vaccines is sensible.
  3. 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 – these are live vaccines and the best advice is to avoid these until safety data are available if you are on the medications listed below.

By the time you are offered a vaccine we will have safety data from many hundreds of thousands of people to reassure us. Despite the known adverse effects which have been associated so far, it remains clear that the risk of harm from covid is much greater.  It is very clear that Covid is here to stay, and if you choose not to be vaccinated you are almost certainly eventually going to be infected

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:

  • Methotrexate
  • Azathioprine
  • Leflunomide
  • Mycophenolate
  • Cyclophosphamide
  • Prednisone (dose and time related)
  • JAK inhibitors
    • Xeljanz
    • Rinvoq
  • Biologics
    • all anti-TNF drugs (eg etanercept, adalimumab, infliximab, golimumab, certolizumab and biosimilars of these);
    • Tociluzimab
    • Abatacept
    • Secukinumab
    • Sarilumab
    • See note below.

Hydroxychloroquine or Sulfasalazine either alone or in combination are not considered immunosuppressive.

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 one week 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.

Do not stop any other medications. Call us if you need advice

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. If you have rituximab due in the next 2 months, again call us.

Will my medications prevent me from developing an adequate immune response? And should I get “the third vaccination”

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. In terms of a booster, at the time of updating this page (Aug 31 2021) our feeling is that we have not seen compelling  published data to be able to recommend what is done. Remember expert opinion is useful, but what we need are good quality studies to inform us

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. As of late August 2021 we have seen about 25 to 30 flares of RA from a patient population of over 2000. So yes, we nbelieve the vaccine could trigger a flare, but we are learning month by month. We still feel this is not a reason to avoid protecting yourself and your family.

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.

Vaccine hesitancy.

We understand and respect many of the anxieties patients describe to us.  Our position is unambiguous – eventually if you are not vaccinated you should accept that you will probably get the virus. If you are vaccinated you are massively less likely to end up in the ICU or dead. But the data are indeed confusing and there are some strongly help opinions

You will not be surprised that many of our patients claim an expertise and level of knowledge that exceeds that of many scientists and our own….  and for these, we recommend they purchase the following:

Resources:

https://www.rheumatology.org.uk/practice-quality/covid-19-guidance