Rheumatoid arthritis

Stopping DMARDs and disease flares: how rheumatology patients fare with COVID-19 vaccination

Patient-reported side effects among adults with systemic rheumatic disease who were vaccinated for COVID-19 were of similar nature to those being reported by the general population, suggest results of an international survey published in the BMJ journal RMD Open.

Other key findings from the global COVID-19 Global Rheumatology Alliance (C19-GRA) survey are that the majority of patients were willing to temporarily discontinue treatment with DMARDs to boost vaccine efficacy, and that the frequency of rheumatic disease flares requiring a change to medication was reassuringly low.

The team, led by Dr Sebastian Eduardo Sattui, from the Division of Rheumatology at New York’s Hospital for Special Surgery, analysed responses from 2,860 adults with systemic rheumatic diseases who had received COVID-19 vaccination with Pfizer-BioNTech (53%), Oxford/AstraZeneca (23%), Moderna (21%), Janssen/Johnson & Johnson (2%) and other vaccines (1%).

The most common rheumatic disease in the cohort was rheumatoid arthritis (42%), followed by inflammatory myositis (17%), Sjögren’s syndrome (15%), systemic lupus erythematosus (13%) and spondyloarthritis (9%), and 81% of respondents were taking a DMARD for their condition.

Almost half of survey respondents (48%) experienced at least one adverse event lasting for at least 2 days post-COVID-19 vaccine, but these were typical of those observed in the general population: fatigue or sleepiness (33%), headache (28%), and wide-spread muscle/joint pains (22%). Only six patients reported an episode of anaphylaxis.

Also, the frequency of adverse events and disease flares was similar across vaccine types, and while flares of existing systemic rheumatic disease were reported by 13% of participants, just 5% required a subsequent change in treatment.

Most study respondents (67%) said they were willing to temporarily discontinue DMARDs to improve vaccine efficacy, despite fears over experiencing a rheumatic disease flare as a result (44%).

Similarly, most patients (82%) said they would stop taking methotrexate if it meant achieving a better vaccine response, and while the number of those willing to stop treatment with systemic glucocorticoids (49%) was less, this could be explained by “prior experience of flares when stopping or lowering dose of glucocorticoids, concerns about adrenal insufficiency or a relationship between glucocorticoid use and active disease,” the authors said.

However, despite the reported willingness to do so, 71% said they did not stop their medication before or after receiving the vaccine. “Future studies are needed to firmly establish an evidence base for temporarily holding specific antirheumatic therapies to enhance vaccine efficacy while balancing risk for disease flare,” the authors noted.

The study findings also depicted an “encouraging” picture of the level of communication between rheumatic disease patients and their physicians, with most (82%) reporting having discussed COVID-19 vaccination with their healthcare provider. The authors highlighted that “almost all participants who discussed vaccination with a provider were recommended to receive a COVID-19 vaccination and respondents were overall satisfied with COVID-19 vaccine-related conversations with their clinicians”.

Nevertheless, they also emphasised that “clinicians should maintain awareness of changing guidelines as further data become available to provide continued communication and patient counselling regarding risks and benefits of vaccination.”

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