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Antibody Levels After COVID Vaccine

posted in COVID-19 on September 19, 2021 by

Donald Thomas

Some Immunosuppressant Drugs Cause Lower Antibody Levels after COVID Vaccine than do Other Drugs

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A large study was published in the Annals of Rheumatic Diseases showing antibody levels after COVID vaccine in patients on immunosuppressants. These drugs were taken by patients with systemic autoimmune diseases (such as rheumatoid arthritis, lupus, spondyloarthropathies, and vasculitis).

Since these drugs decrease immune system activity, it is not surprising that some of them appeared to lower the chances of someone responding to the COVID-19 vaccine. However, they varied a lot in how much they suppressed antibody responses. The investigators measured the most important antibody response called the SARS-CoV-2 spike S1/S2 proteins. Antibody levels were also measured two to four weeks after the second vaccine dose of the Pfizer mRNA vaccine.

Remember that infections are in the top 3 causes of death in systemic lupus. It is important to get all vaccines as per “The Lupus Secrets.”

Antibody levels after covid vaccine using the Pfizer mRNA vaccine in patients on immunosuppressants
Investigators measured antibody responses 2-4 weeks after the 2nd shot of the Pfizer mRNA vaccine

Immunosuppressants Lowered the Antibody Levels after COVID Vaccine by Varying Degrees

The study showed that some drugs lowered the chances of an adequate antibody response by a lot (such as rituximab). However, others, such as hydroxychloroquine (Plaquenil), leflunomide (Arava), and anti-cytokine drugs (such as adalimumab, etanercept, infliximab) had close to a 100% response.

Below shows the percentage of patients taking the different immunosuppressants who developed a newly positive anti-spike IgG antibody response after their second Pfizer vaccine.

Immunomodulating Drug Responses by the Numbers

  • rituximab (Rituxan): Only 39% of patients taking rituximab responded
  • mycophenolate mofetil (CellCept): 64%
  • abatacept (Orencia): 71%
  • steroids (average of 6.7 mg daily of prednisone): 77%
  • JAK inhibitors (tofacitinib, Xeljanz, upadacitinib, Rinvoq, baricitinib, Olumiant): 90%
  • methotrexate: 92%
  • anti-cytokine biologics (TNF-inhibitors, etanercept, adalimumab, infliximab, IL-6 inhibitors, IL-17 inhibitors): 98%
  • leflunomide (Arava) and hydroxychloroquine (Plaquenil): close to 100% responded

My caveats:

It is interesting that 92% of those on methotrexate (MTX) had a response. Other studies show that MTX patients have lower responses to vaccines. These numbers run between 72% and 84% response rates. It is now common place to ask our patients to stop their MTX for 2 weeks after all vaccines. I wonder if this intervention may have contributed to the high 92% response rate noted in this study.

Also, note the 77% response by patients taking steroids. Their average steroid dose was around 7 mg of prednisone daily. Higher doses of prednisone lower the response rate to vaccines. This number would have been much lower in patients taking more than 10 mg a day.

Some Patient Groups did Worse than Others

Some patients on these drugs had a higher chance of not responding compared to others. These included:

  • Patients older than 65 years old
  • Patients with rheumatoid arthritis, inflammatory myositis, ANCA-associated vasculitis
  • Caveat: patients with lupus were not commented on specifically
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What You Can Do to Increase Your Antibody Levels After COVID Vaccine

If you are on those drugs noted to have the largest chances of reducing vaccine responses, all is not lost! The American College of Rheumatology has put out guidelines on stopping immunosuppressants that may lower the response rate to vaccines. As more information also comes in over time from additional research, these recommendations are being changed over time.

Some of these recommendations are a little confusing and not uniform, however. The ACR committee in charge of these guidelines is supposed to meet again in September 2021 and hopefully clean up the list of recommendations.

Examples of nonuniformity include the following:

  • Some immunosuppressants, such as azathioprine (Imuran) and leflunomide (Arava), are not recommended to stop for the 1st two Moderna and Pfizer mRNA vaccines, yet the committee recommends that “immunosuppressants” be stopped for 2 weeks after the 3rd (booster) shot. This implies that Imuran and Arava should be stopped.
  • Other immunosuppressants have specific timings recommended for the 1st two Pfizer and Moderna shots (such as for abatacept and JAK inhibitors), yet there is a blanket recommendation of stopping “immunosuppressants” for 2 weeks after the 3rd booster shot.

To avoid confusion on your part, it is best to ask your rheumatologist their opinion and recommendations based upon your clinical situation. For example, if you are at high risk of flaring by stopping any medications, your rheumatologist may recommend that you not stop any of your medicines.


  • Some immunosuppressants can reduce antibody levels after COVID vaccine
  • You may have a better chance of responding if you stop certain drugs for your vaccines
  • Ask your rheumatologist how to deal with your medicines and your vaccines
  • Rituximab (Rituxan) is the biggest culprit in lowering vaccine responses. Generally, you should get your vaccines 2-5 weeks before rituximab (but check with your doctor). This is the most complicated drug to deal with (IV abatacept is a close 2nd in complexity).

Dr. Donald Thomas advises: Getting rituximab (Rituxan) between May and September can cause difficulties with timing your flu vaccine appropriately. You should time your flu (influenza) shot to be given 2-5 weeks before rituximab treatment. Since the best time to get the flu shot is in September and October, it is best to get your rituximab in early October to late November in order to time your flu shot properly.

One common example where problems may occur is when your rituximab is given in early September and you get it every 6 months. To time the flu shot properly, you would have needed to get it around early August, but that is too early. Your next rituximab would be in March the next year meaning your flu shot is best given in February when that year’s flu season is almost over.

It is best to prepare ahead of time. For example, I would recommend to my patients that they postpone their rituximab to early October and get their flu shot in the middle of September instead.





by Donald Thomas, MD; author of “The Lupus Encyclopedia” and “The Lupus Secrets


ACR COVID-19 Vaccine Clinical Guidance Task Force. COVID-19 Vaccine Clinical Guidance Summary
for Patients with Rheumatic and Musculoskeletal Diseases

Friedman MA, Curtis JR, Winthrop KL. Impact of disease-modifying antirheumatic drugs on vaccine immunogenicity in patients with inflammatory rheumatic and musculoskeletal diseases. Annals of the Rheumatic Diseases 2021;80:1255-1265.



  1. I’m on prednisone 10mg, mycophenolate mofetil 500mg b/d, and hcq 200mg b/d. Doctor asked me to stop only the mycophenolate mofetil 7 days before and 7 days after. I took the moderna on 1st Sept, due for the 2nd dose 29th sept. Honestly I’m worried because I’ve been having feelings in my feet and chest pain. I’m supposed to stop the mycophenolate mofetil again on 22nd Sept, but with the way I’m feeling I’m worried. I wish I could book an appointment with you Dr. T but I live in Nigeria.

    • Deborah: Sorry about the late response, and thanks for commenting. I sure hope you are doing OK and that you got your vaccines (I’ve seen too many horrible things in my unvaccinated patients). Feeling badly after the vaccine (often due to the immune response) is much better than COVID 19 infection consequences. Though the ACR recommends stopping CellCept for 2 weeks after the vaccine, this is not based on perfect science. There is nothing to say that stopping it 1 week before and 1 week after is not as good (ie your rheumy may be right). Don’t forget to get your 3rd shot. It is recommended to get it 28 days after your second shot in immunosuppressed patients. The Moderna is the best vaccine. Make sure to get a full shot and NOT half dose (half dose is recommended for the general population). Also, get a 4th vaccine 6 months after #3 (newest recommendation). I wish you all the best! … Donald Thomas MD

  2. Thanks

  3. I got my Phizer booster 3 weeks ago. My rheumatologist told me to stop cellcept for one week afterwards. I have been diagnosed with lupus and I also have heart problems. The cardiologists are trying to decide if it is lupus myocarditis, sarcoidosis, or ARVC.

    • Michelle: Make sure to ask your rheumy about getting a 4th shot 6 months after your 3rd (per the newest guidelines). If you were my patient, I’d ask you to stop CellCept for 2 weeks after the vaccine if you were at low risk of flaring. Good luck!… Donald Thomas, MD

  4. This article was a bit confusing. It was testing if our antibodies lowered. And it says next to plaquenil 100% responss rate.. Is this indicating that there was a 100% response meaning that there was no lowered response to immunity Being on this medication? My dr recommended nothing different. I am on plaquenil and trying to determine next best step and if I really need a booster sooner.

    • Jennifer: Sorry about the late response. Correct, Plaquenil patients had nearly a 100% response to the vaccine! Wonderful! Not surprising since Plaquenil does not suppress the immune system. Please do get your booster (I got mine). Reason… , Lupus patientshave an abnormal immune system and you need all the protection you can get. I wish you all the best! … Donald Thomas, MD

  5. If I take prednison 7.5 mg, cellcept 2000 mg and benlysta infusion once a month, my chances are even lower of getting a positive response than stated above?

    • Kristina: Unfortunately, “yes”, to the prednisone plus CellCept… the Benlysta is , probably fine policy. In my experience so far, my patients like you are at least having partial spike antibody responses. Make sure to get your 4th vaccine 6 months after your 3rd vaccine. If you were my patient I would… try to slowly lower your prednisone dose if possible (eg try 7 mg for a month, then 6 mg for a month, etc), and stop CellCept X 2 weeks after the next vaccine… I wish you all the best… Donald Thomas, MD

  6. I moved quickly to get my third Pfizer shot as soon as it was announced. I was unaware of any recommendations to stop my Enbrel, for RA treatment, following the third shot. I got the shot on the day I would normally have self administered my 50 ml. dose. I held off on dosing until 72 hours later.

    • Patience: thanks for reading and posting. The latest ACR Guidelines now say that cytokine inhibitor biologics (like Enbrel) do not need stopped. More recent studies showed they did not blunt vaccine responses… Donald Thomas, MD

  7. Thank you for this invaluable research!

  8. I appreciate the information provided here however I am on both Cellcept (for Sjögren’s syndrome) and Bulimimab (Benlysta) and prednisone for control of my Lupus. Do you have information on the efficacy of the covid vaccine in patients using Benlysta? My husband and I are both in our 70s and received the J & J vaccine in March.

    • I do not have data on belimumab and COVID vaccines yet (it is being studied). However, I think it will work. Rationale: a study showed excellent responses to Pneumococcal vaccines in a study by Chatham et al (reference below). I just received the results of the COVID spike protein antibody response to the COVID vaccine in one of my Benlysta patients. Her level was an incredible >24,999 … it was done in the NIH COVID vaccine study, so I’m confident on the accuracy results. Good luck to you and your husband! Also… keep in mind a new recent recommendation is for immunosuppressed patients to get a 4th vaccine 6 months after your 3rd. … Thanks for reading my blog and commenting… Dr Donald Thomas… REFERENCE: Journals Sagepub

  9. I’ve got lupus, COPD and High BP.
    I’m on zartan 50mg,salazoprin-en, chloroquine sulphate,coxleon 200mg,robaxin,ultibro breezhaler,ciclovent,fluticasone furoate,allerway 5 and trepiline 25g.
    I’m a police officer and unvaccinated. Every morning when I take my meds I take it with 5drops of H²O² 20 volume in a big glass of water. If I feel a scratchy throat and itchy ears I take allergex. I’ve never felt beter.

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