Vaccine choice
“Should you prefer one vaccine or vaccine platform to another? That’s been incredibly controversial,” Dr. Curtis said. Though the efficacy of the mRNA vaccines is often cited at 90%, compared with the roughly 60%-70% efficacy of the Johnson and & Johnson single-dose vaccine, “they’re not head-to-head studies. They weren’t done in the same countries; they weren’t done with the same viral variants. They’re not being evaluated under similar conditions; it’s not fair to hold them up and say: ‘Apples to apples, this one is better than that one.’ ”
“On the other hand,” he added, “if you were choosing, which would you want? If you are given a choice, you’re probably going to have a preference. The downside for a public health group – this group, which is trying to help rheumatologists and their patients make prudent decisions in light of very imperfect and evolving evidence – is that most people don’t have a choice. So if you send the message that one vaccine might be better than another, if that makes people wait for the one that supposedly might be better, you’ve probably done something bad. They’re delaying for what may be a marginal reason, and some vaccine protection is better than no vaccine protection.”
Regarding vaccination timing in patients who are on immunomodulatory therapies, the task force strongly recommended not delaying or adjusting the timing for anyone on hydroxychloroquine, sulfasalazine, leflunomide, apremilast, or intravenous immunoglobulin. They moderately recommended the same for patients on numerous drugs, including methotrexate, tumor necrosis factor inhibitors, Janus kinase inhibitors, abatacept, and glucocorticoids. Patients on rituximab with a low COVID-19 risk were recommended to schedule their vaccination so that the vaccine series is initiated roughly 4 weeks before their next scheduled rituximab cycle.
Regarding the use and timing of immunomodulatory therapies in relation to vaccination, they strongly recommended no modifications for patients on hydroxychloroquine, apremilast, intravenous immunoglobulin, or glucocorticoids. They also moderately recommended no modifications for patients on numerous drugs, including sulfasalazine, leflunomide, azathioprine, oral cyclophosphamide, and TNF inhibitors.
Regarding limitations, the researchers noted that there is no direct evidence about COVID-19 vaccine safety and efficacy yet in this subset of patients. They also acknowledged that they did not follow the rigorous methodology typically used by the ACR in developing formal clinical practice guidelines, calling it an “expected limitation” given the need to issue timely and potentially lifesaving guidance for the rheumatology community.
The authors acknowledged several potential conflicts of interest, including receiving consulting fees, speaking fees, and research grants from various pharmaceutical companies.