Coronavirus: Must-Know Info

5 Things People With Rheumatoid Arthritis Need to Know About the COVID-19 Vaccines

Learn about the safety, effectiveness, and importance of a full course of COVID-19 vaccines if you or a loved one is living with rheumatoid arthritis.

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With new developments in COVID-19 prevention, there’s still plenty to learn about how, and why, to stay up to date on shots.Shivendu Jauhari/iStock

The good news is that immunizations for COVID-19 are easily available for most people in the United States. They’re offered free for all Americans — regardless of immigration or health insurance status — at drugstores and other locations within 5 miles of where most people live, according to the Centers for Disease Control and Prevention (CDC). (You can find a location near you on the federal government’s website.)

That means that most Americans can be protected from the most serious complications of this viral disease.

The bad news: Some 17 percent of eligible Americans have not gotten a single shot. If you have been holding back because you have questions, especially if you or a loved one have rheumatoid arthritis (RA), this article should help.

Based on the growing body of research, as well as expert insights, here are five things you should know about the COVID-19 vaccines.

COVID-19 Vaccination for People With Rheumatic Disease

COVID-19 Vaccination for People With Rheumatic Disease

1. It’s Crucial That People With Rheumatoid Arthritis Get the COVID-19 Vaccine

COVID-19 is a serious disease. It has now killed more than a million Americans and has left others with lingering symptoms known as long COVID, including extreme fatigue, shortness of breath, and brain fog.

Fortunately, having RA or another autoimmune condition in and of itself does not seem to make COVID-19 more deadly, says Lynn Ludmer, MD, a rheumatologist at Mercy Hospital in Baltimore.

But the same cannot be said for people on immune-weakening medicines — which includes many people with RA — or those with cardiovascular disease, a potential complication of RA. Those circumstances do increase the risk of severe COVID-19 outcomes if a person contracts COVID, according to the Centers for Disease Control and Prevention (CDC).

That’s why the American College of Rheumatology (ACR) states that all RA patients should be vaccinated. In guidance first released in February 2021 by the ACR’s North American Task Force, composed by 13 experts and updated several times, most recently February 2022, the ACR emphasizes that there are no known RA contraindications to the COVID-19 vaccine unless someone is allergic to the vaccine’s components.

The group also recommends that people with RA get an mRNA vaccine, such as those made by Pfizer-BioNTech or Moderna, rather than a non-mRNA shot like Johnson & Johnson’s. For autoimmune inflammatory rheumatic disease (AIIRD) patients not yet vaccinated, either of the mRNA vaccines is recommended over the J&J vaccine. There is no recommendation for one mRNA vaccine over another.

Experts Worry About Vulnerability of People Who Take Some RA Drugs

Reports from the Global Rheumatology Alliance, an international registry of people with RA who develop COVID-19, point to the importance of COVID-19 vaccinations for people who are immunocompromised as a result of their RA medication, because they are at higher risk of poor outcomes from the coronavirus.

Results from the experiences of some 3,700 patients from this registry, published in January 2021 in Annals of the Rheumatic Diseases, revealed that use of more than 10 milligrams (mg) of steroids per day with moderate to high RA disease activity leads to a greater likelihood of adverse outcomes with COVID-19 infection.

Another report from the Global Rheumatology Alliance, published in September 2021 in Annals of the Rheumatic Diseases, based on the COVID-19 disease experience of nearly 3,000 people with RA, showed that people on rituximab or Janus kinase inhibitors (JAKs) have more severe COVID-19 disease, including hospitalization and in some cases death, than people who took other medications, especially TNF inhibitors.

The ideal is for people to have their RA well controlled when they get their vaccines. But the ACR task force says everyone should be vaccinated regardless of their current disease state. The group also emphasizes that their recommendation for the vaccines includes everyone who has previously contracted COVID-19.

2. Two Shots Aren’t Enough. You May Need a Third Dose — Plus Boosters

In August 2021, the CDC added a new recommendation for people who are “moderately or severely” immunocompromised, including those who take systemic immunocompromising drugs, and have received an mRNA vaccine: They should get a third dose of the vaccine some 28 or more days after the second dose. Talk to your rheumatologist about whether the drugs you take put you in this category.

It’s important to note that this third shot is not a booster (more on those below), but rather an additional primary dose in the series. The third shot should be the same full strength as the original shots, the CDC says.

The reason for the third shot is that people who are compromised, including from immune-suppressing medications, don’t always mount a sufficiently robust immune response following the two-dose series.

This became clear after a study of people with RA in Israel, a country with an early high rate of vaccinations. The research, published in October 2021 in Annals of the Rheumatic Diseases, found that some 86 percent of people with RA mounted a strong immune response to the vaccines, compared with 100 percent of those without the disease. The study specifically noted that rituximab (Rituxan) significantly reduced the immune response, and there was also a moderate decrease in people on abatacept (Orencia), mycophenolate mofetil, and glucocorticoids (at a mean dose of 6.7 ± 6.25 mg/day. )

An abstract presented at the virtual annual meeting of the American College of Rheumatology (ACR) in November 2021 by researchers from Washington University in St. Louis found that the impact of medications was even more stark. Compared with a healthy control group, people with autoimmune diseases had a threefold reduction in certain antibodies following their COVID-19 vaccines, an effect especially seen in people on glucocorticoids, the researchers found.

That third shot seems to make a significant difference, especially for patients on Rituxan (rituximab). Another study presented at the virtual ACR conference found that although the immunocompromised patients taking rituximab did not produce sufficient antibodies after their first two mRNA vaccines, they did get a stronger immune response after a third shot (from any manufacturer).

The recommendation for this additional primary shot is separate from the booster shot recommended for everyone, including children ages 5 to 11, months after they have completed their regular series.

According to the CDC, immunocompromised people who have completed the three-shot series should get an initial mRNA booster shot three months after the additional primary shot. This is different than their recommendation for people who are not immunocompromised, including children, who are recommended to get their initial booster five months after completing their primary series.

Everyone whose first vaccine was the single-dose J&J shot is encouraged to get a second shot with a more effective mRNA vaccine, followed by a booster two months later.

The CDC has also approved a second booster for certain people, including everyone age 12 and older who is immunocompromised, as well as people age 50 and older and any adult who has only had shots of the J&J vaccine (primary dose and booster).

After reviewing the data, the FDA also authorized a mix-and-match approach to boosters, meaning anyone can get any shot, even if it is different from their original shot. People who received the J&J vaccine are especially found to have a larger antibody rise if they get one of the mRNA vaccines as the booster, the FDA found.

3. Work With Your Doctor to Shift Your RA Medications

Because of the possibility that certain RA medications will interfere with a person’s ability to manufacture antibodies against COVID-19 after a shot, the ACR task force recommends that patients work with their doctors to consider shifting the timing of some common RA medications when feasible, in an effort to enhance this immune response.

These recommendations are not intended to replace a doctor’s clinical judgment.

Medications include:

  • Methotrexate They recommend pausing for one week after each mRNA vaccine dose and two weeks after the Johnson & Johnson vaccine, if the disease is well controlled.
  • JAK inhibitors Pause for one week after each dose, regardless of the patient's state of disease.
  • Abatacept (Orencia) For subcutaneous delivery, pause for one week before and one week after the first dose only. For IV delivery, time the first vaccine to occur four weeks after the drug's infusion, then postpone the subsequent infusion by one week, for a five-week gap. For those not yet on subcutaneous or intravenous abatacept, therapy should be delayed until the recommended one week after the first vaccine dose has passed.
  • Rituximab (Rituxan) Schedule vaccine about four weeks before next scheduled cycle, and delay the drug two to four weeks after the vaccine series is completed, if possible.
  • Cyclophosphamide (Cytoxan) Time drug administration about one week after each vaccine dose, if possible.
  • Mycophenolate Pause for one week after each vaccine dose if your disease is stable.
  • Acetaminophen and NSAIDs Assuming the disease is stable, withhold for 24 hours prior to vaccination. (There is no restriction on post-vaccination use to treat symptoms.)

There are currently no recommendations to alter drug regimens for hydroxychloroquine, intravenous immunoglobulin (IVIG), prednisone less than 20 mg per day, sulfasalazine, leflunomide, mycophenolate, azathioprine, cyclophosphamide, TNF inhibitors, belimumab, oral calcineurin inhibitors, or IL-6R, IL-1, IL-17, IL-12/23, or IL-23.

4. Don’t Worry About Minor Side Effects

Studies have provided reassurance about side effects of the COVID-19 vaccines for people with RA.

According to a report published in JAMA in February 2022, data from more than 5,000 people in 30 countries with rheumatic disease has indicated minimal problems after getting the shots. (The data was drawn from a voluntary registry collected by the European Alliance of Associations for Rheumatology.)

Some 70 percent of the people in the registry received the Pfizer-BioNTech vaccine, 8 percent got the Moderna vaccine, and the rest received the Oxford/AstraZeneca vaccine, which is not available in the United States.

While many of them experienced muscle pain or fever, which is a common side effect among all people, only 4 percent experienced a flare of their rheumatic disease, with most of the flares being mild or moderate. Just 1.5 percent needed a new medicine or increased dose of their drug to treat the symptoms of the flare. And only 0.5 percent of the vaccine recipients experienced a severe adverse event.

Additionally, some 1,500 people with RA and other rheumatic diseases who had their experiences recorded in Europe’s EULAR COVID-19 Vaccination Registry (COVAX) generally developed short-term side effects similar to those in the general population, according to a report at the virtual EULAR conference and published in the Annals of the Rheumatic Diseases in May 2021.

In the study, only a small percentage, some 5 percent of vaccine recipients, experienced a flare in their rheumatoid disease following their inoculations, with just 1.2 percent rating it as severe.

Researchers presenting at the November 2021 ACR virtual conference similarly confirmed that the vaccines are not associated with severe RA disease flares. In this study of 220 participants, of whom about half had RA and 58 had no disease, nearly a quarter of those with RA did report getting swollen joints following each vaccine dose, but there was no overall increase in disease activity scores.

The CDC emphasizes that the COVID-19 vaccines currently authorized are safe and effective, including for people on many medications. “Millions of people in the United States have received COVID-19 vaccines under the most intense safety monitoring in U.S. history,” the agency states.

Common side effects for everyone getting a COVID-19 vaccine include pain, redness, and swelling in the arm that was injected, as well as tiredness, muscle pain, headaches, chills, fever, or nausea.

Anyone experiencing these bothersome side effects should speak with their doctor about taking over-the-counter medicine, such as ibuprofen, acetaminophen, antihistamines, or (for those 18 and over) aspirin, the CDC says.

More serious adverse reactions should be reported to your doctor as well as to the federal government’s Vaccine Adverse Event Reporting System (VAERS). Do remember that anyone can report anything to VAERS, so unless someone’s adverse reaction was vetted by scientists, you should not necessarily give credence to social media reports of side effects people have seen on VAERS.

5. Keep Up Other Measures to Protect Yourself

It’s important to remember that people who are immunocompromised are at greater risk of developing severe COVID-19 disease, even if they have been vaccinated.

The CDC website makes this point specifically: “People who have a condition or are taking medications that weaken their immune system may not be protected even if they are up to date on their vaccines.”

That’s why the CDC strongly recommends that people who are immunocompromised from medication “should continue to take all precautions recommended for unvaccinated people until advised otherwise by their healthcare provider.” The ACR guidance emphasizes this as well.

This protection includes properly wearing a well-fitting mask indoors around other people, opening a window or otherwise improving the ventilation inside, staying six or more feet from others, washing your hands often, and taking a COVID-19 test if you develop symptoms.

It is especially important to follow these steps when the level of transmission of the coronavirus in your community is rated as being substantial or high.