Lupus Encyclopedia

REFERENCES:

The Lupus Encyclopedia

​Fanouriakis A, Kostopoulou M, Cheema K, et al. 2019 Update of the Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA–EDTA) recommendations for the management of lupus nephritis. .Annals of the Rheumatic Diseases 2020;79:713-723.

QUESTION: How effective is just one COVID-19 vaccine if you did not get the second?

ANSWER: 82%

Type of study? A Centers for Disease Study

Where? 33 sites in 25 states (U.S. study)

Who? Health Care Provider recipients of Pfizer and Moderna vaccines

Results? One vaccine offered an 82% protection rate (Pfizer, Moderna)

94% for 2 doses. This similar to what we saw in the clinical trials

How about people with lupus, Sjogren's and other autoimmune diseases?

- They were not studied
- However, there are active studies being done at the NIH, Johns Hopkins, etc
      - If you live near Bethesda, MD, call the NIH nurses at 301-435-4489 and 301-451-4990; tell them Dr. Thomas sent you

- If you have an autoimmune disorder, especially if you are on immunosuppressant therapy, you are at higher risk of bad outcomes from COVID-19 infection.
- It is imperative you get vaccinated
- Make sure to stop your immunosuppressants appropriately for vaccination (but ask your doctor 1st to check)
     Here is a link on how to stop meds for the vaccines: 

https://www.lupusencyclopedia.com/blog/what-to-do-with-your-immunosuppressant-drugs-to-enhance-vaccine-responses

- If you get vaccinated, pretend you are as vulnerable as if you did not get vaccinated
      - Still practice social distancing
     - Ignore the CDC guidance for others who are vaccinated... i.e. still wear your masks and socially distance from everyone and plead the unvaccinated to just stay away from you (I always worry about my patients)

https://t.co/uQhUmjSsRd


REFERENCE: ACR, COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases. Developed by the ACR COVID-19 Vaccine Clinical Guidance Task Force.

​Pilishvili T, Fleming-Dutra KE, Farrar JL, et al. Interim Estimates of Vaccine Effectiveness of Pfizer-BioNTech and Moderna COVID-19 Vaccines Among Health Care Personnel — 33 U.S. Sites, January–March 2021. MMWR Morb Mortal Wkly Rep. ePub: 14 May 2021. DOI: http://dx.doi.org/10.15585/mmwr.mm7020e2external icon.
​

revised 6/13/21: Added mycophenolate, NSAIDs, and Tylenol to the list of drugs that should be held for vaccines

SARS-CoV-2 vaccines in patients with SLE
Link and reference below to the research studies

Summary of some main points (but I encourage you to read the article):

- This article is written by some of the world's experts in lupus 
     - Dr. Joan Merrill, Dr. Anca Askanase, Dr. Wei Tang, and Dr. Leila Khalili

"... the risks of not receiving the vaccine are far greater at the present time."

- The lupus experts also state,
     "Patients with autoimmune rheumatic diseases should receive the COVID-19 vaccines and should be prioritized before the general population." 
- Other vaccines have been shown to be safe in lupus patients.
- They recommend temporarily stopping or changing the dosing schedule on some drugs, such as cyclophosphamide, methotrexate, mycophenolate (CellCept, Myfortic), rituximab (Rituxan), abatacept (Orencia), JAK inhibitors (Xeljanz, Olumiant, Rinvoq), NSAIDs, and Tylenol.

     - They recommend following the recommendations of the American College of Rheumatology (click on link)

- They recommend that doctors may want to consider monitoring antibody levels after the vaccine.
- Since we do not know how well lupus patients, patients with other autoimmune diseases, and immunosuppressed patients will respond to the vaccines, they should continue strict social distancing.
- The above recommendations are made without research regarding specifically these RNA vaccines. However, after evaluating all the data, The American College of Rheumatology and these lupus experts recommend vaccination in patients with autoimmune rheumatic diseases. 

What are the risks of COVID-19 infection when lupus patients get infected?

- They are not at higher risk for infection from the novel SARS-CoV-2 Coronavirus.
- However, they are at higher risk of hospitalization than the general population. 
- COVID-19 infection may even increase lupus flares.

Please get your vaccine.  I got mine and I recommend it to all my patients. 
This is not a substitute for your doctor's advice. Please check with your physician first. 

References:
Tang W, Askanase AD, Khalili L, et al. SARS-CoV-2 vaccines in patients with SLE. Lupus Science & Medicine 2021;8:e000479. doi: 10.1136/lupus-2021-000479

​American College of Rheumatology (ACR) COVID-19 Vaccine Clinical Guidance Task Force. COVID-19 vaccine clinical guidance summary for patients with rheumatic and musculoskeletal diseases, 2021www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf. Available: https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdfGoogle Scholar

BAD FINDINGS FROM THE STUDY

Rheumatic disease patients at highest risk for death after infected with COVID-19 (listed in order)
(these results will be given in odds ratios.
To figure out how to word this (odds ratio findings):
Subtract 1 from the number, move the decimal point 2 to the right, then say "___ greater odds of dying from COVID-19."
For example, for an 80 year old with a rheumatic disease, they have a 518% greater odds of dying from COVID-19. A man with a rheumatic disease has a 68% greater odds of dying from COVID-19 infection than a woman does.")

     - Age >75 years old, OR 6.18
     - Rituximab (Rituxan) treatment, OR 4.04
     - Sulfasalazine treatment, OR 3.60 (see commentary below)
     - Age 66-75, OR 3.00
     - Immunosuppressant treatments listed below, OR 2.22
                 (tacrolimus, mycophenolate, cyclosporine, cyclophosphamide, azathioprine)
     - Not on a disease modifying agent immunosuppressant, OR 2.11 (compared to patients on methotrexate)
     - Moderate to high disease activity, OR 1.87 (compared to patients in remission and low disease activity)
     - High blood pressure plus heart disease, history of stroke, or hardening of the arteries, OR 1.89
     - Prednisone more than 10 mg daily (or more than 8 mg methylprednisolone), OR 1.69 (compared to no steroids)
     - Chronic lung disease (like COPD, asthma, interstitial lung disease, pulmonary fibrosis), OR 1.68
     - Men, OR 1.46 (compared to women)

United Kingdom had the highest death rate followed by Germany

________________________________________________________________

Commentary about sulfasalazine (SSZ): Do not take away from this that SSZ increases deaths from COVID-19. SSZ is often prescribed by rheumatologists to sicker patients who are at higher risk for infections in the first place. For example, there were more smokers in the SSZ group. SSZ does not suppress the immune system. Also, SSZ is a weak drug (most often used to treat rheumatoid arthritis). Patients on just SSZ are less likely to be in remission or low disease activity (and therefore at higher risk of death from a COVID-19 infection). I suspect that this is an "association" and not a "causality."
​

POSITIVE FINDINGS FROM THE STUDY

     - Hydroxychloroquine (Plaquenil) and belimumab (Benlysta) treatments were not associated with higher death
    - TNF inhibitor, leflunomide, abatacept (Orencia), tocilizumab treatments were not associated with higher death 
     - The United States had the lowest death rate of all countries in the study
          - After the US, countries (in order) of lowest death rates = Germany, then France, then Spain

BOTTOM LINE AND WHAT YOU SHOULD DO TO PROTECT YOURSELF:

- It is most important to keep your lupus under control. Do NOT stop any medications.
- Abide by all nondrug ways to lower lupus disease activity so you don't need as many steroids.
- Work hard with your doctor to control your disease better so you can lower your steroid dose. 
- Get vaccinated against COVID-19!
- Ask everyone around you to get vaccinated (the cocoon strategy)
- Even after vaccination, abide by all isolation, separation, social distancing strategies


Reference: Strangfeld A, Schäfer M, Gianfrancesco MA, et al. Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry. Annals of the Rheumatic Diseases Published Online First: 27 January 2021. doi: 10.1136/annrheumdis-2020-219498

Revised 6/13/21 with new drugs to stop for vaccines per revised ACR recommendations

February 2021, the American College of Rheumatology released recommendations on what to do with immunosuppressant drugs around the time of your COVID-19 vaccine. The reason for these recommendations is that some of our medicines can blunt the effects of the vaccine. Timing the drug to the vaccine to your medication can make a big difference.

ALSO: They make other important recommendations as listed below. Make sure to share this with your family, friends, and other patients

NOTE: 
- Do not do any of these without asking your rheumatologist first (let them know that you did read these up to date recommendations here)
- PRINT these out for future reference for other vaccines
- I also recommend these to my patients who get any vaccine, IF they are in remission or at low risk of flaring when they get the vaccine (again, do not do this without talking to your rheumatologist first)
- I agree with all of these, except, I differ with the methotrexate recommendation, as per below

The link to the full recommendations is below at the bottom of the post. 

Abatacept IV (Orencia): Time vaccine administration so that the 1st vaccine occurs 4weeks after Orencia IV (i.e.,        the  entire dosing interval), and postpone the subsequent IV Orencia by 1 week (i.e., a 5-week gap in total); no medication adjustment for the second vaccine dose
Abatacept SQ (Orencia self injectable): Hold SQ abatacept both one week prior to and one week after the first
     COVID-19 vaccine dose (only); no interruption around the second vaccine dose
Azathioprine (Imuran): No modification needed
Belimumab (Benlysta): No modification needed
Cyclophosphamide: No modification needed for pills. For the IV form, time CYC administration so that it will occur approximately 1 week after each vaccine dose, when feasible.
Hydroxychloroquine (Plaquenil): No modification needed
IVIG: No modification needed
JAK inhibitors (Xeljanz, Olumiant, Rinvoq): Hold JAKi for 1 week after each vaccine dose
Kineret: No modification needed
Leflunomide (Arava): No modification needed
Methotrexate: Hold MTX 1 week after each vaccine dose, for those with well-controlled disease
     NOTE Dr. Thomas' recommendations to his patients: "Hold MTX dose for 2 doses after each vaccine if you are doing well and in remission" (do not do without talking to your own doctor). This is based on the latest study results with the flu shot and methotrexate.
Mycophenolate (CellCept, Myfortic): No modification needed
Prednisone: No modification needed
Rituximab (Rituxan): Assuming that patient's COVID-19 risk is low or is able to be mitigated by preventive health measures (e.g., self-isolation), schedule vaccination so that the vaccine series is initiated approximately 4 weeks prior to next scheduled rituximab cycle; after vaccination, delay RTX 2-4 weeks after 2nd vaccine dose, if disease activity allows.
Sulfasalazine: No modification needed
Tacrolimus and cyclosporine A: No modification needed
TNF inhibitors (adalimumab, etanercept, infliximab, golimumab, certolizumab): No modification needed
Tocilizumab (Actemra): No modification needed
Voclosporin (Lupkynis): No modification needed

- There is no preference of getting one vaccine over another (Pfizer, Moderna, J&J, AstraZeneca): Get whatever is available for you
- Lab testing is NOT required after vaccines to assess response to the vaccine
- Ask all household members, friends and loved-ones to get vaccinated to protect you (the cocoon effect)
- If you don't believe in the vaccine, get vaccinated at least to protect those you love (Dr. Thomas' addition)
- Get vaccinated even if your disease is active

REFERENCE: ACR, COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases. Developed by the ACR COVID-19 Vaccine Clinical Guidance Task Force.
This draft summary was approved by the ACR Board of Directors on February 8, 2021.. A full manuscript is pending journal peer review.

Quick Summary of Important Findings of COVID-19 Transmissions:

- Most infected people do not transmit SARS-CoV-2 (the novel coronavirus responsible for COVID-19)

SUPERSPREADERS!

- Some people are "superspreaders," infecting many people they come into contact with
- Who are these superspreaders? How can we identify them so we can super-quarantine them? 
     - We need to figure this out
     - It is theorized they probably have a "high viral load" (heavily infected, with respiratory droplets that are much more infectious than others)

Resource: Meyerowitz EA, et al. Transmission of SARS-CoV-2: A Review of Viral, Host, and Environmental Factors [published online ahead of print, 2020 Sep 17]. Ann Intern Med. 2020;M20-5008. doi:10.7326/M20-5008

When is someone most infectious?

- Infectiousness occurs before symptoms ever occur
- Infectiousness is at its peak the day before the person develops symptoms
- The infectious period gradually goes away within a week
- There are no cases of transmission more than "about a week" after infection symptoms 1st began

- Definite transmission by "fomites" has not been documented
     - A "fomite" transmission would be touching something the infected person touched
     - Cannot rule out respiratory spread in presumed fomite transmission cases
     - However, fomite-transmission is not ruled out and it is still important to wear gloves and disinfect

- The lowest rate of infection is staying at home, never going out, ordering everything like groceries to be delivered, not allowing anyone to come into contact with you (except another person in the home who does the same)
- If you must come into contact with others, lowest transmission is when both people wear a good mask and are at least 6 feet apart
- Highest transmission rate = indoor social gatherings and not everyone wearing a mask

Read the full article here

- The 2 COVID-19 vaccines available now (Pfizer and Moderna) are RNA vaccines

- It helps to know how RNA works (specifically mRNA)
- Look at the cell above
- We are all born with DNA that codes everything our cells produce. It is responsible for our having blue eyes instead of brown, or black hair instead of blond, or, yes... having funny smelling pee after eating asparagus (or not)
- Our DNA is "transcribed" (think it is as being translated) into RNA, and eventually messenger RNA (mRNA)
- Then, a part of our cells called ribosomes can read this mRNA like a food recipe and produce a particular protein (such as the one responsible for your 2nd toe being shorter, instead of longer, than your big toe)

- The COVID-19 vaccines are NOT live virus vaccines. They CANNOT give you COVID-19 (impossible)
- Ingeniously, they contain the virus' mRNA that codes for those spikes you see on the outside in all the pics
     - These spikes look somewhat like a crown. Latin for "crown" is corona, hence, coronavirus

- Fascinating!
- The mRNA of the virus (in the vaccine) is injected into your muscle
- It spreads quickly throughout your blood stream and body 
- The mRNA is absorbed into our own cells
- Our own cells mistakenly think this mRNA came from our own DNA and instructs those cells to produce this protein
- The protein is the same one found in the spikes of the SARS-CoV-2 coronavirus responsible for COVID-19
     - In other words, our cells produce just those pink spikes you see in the pic below, not the entire virus
- The viral spike protein ends up on the surfaces of our cells
- Our very smart T-cells of the immune system actually DO recognize these as being foreign
- They say, "we need to fight this off and protect us"
- They summon other players of the immune system as well to the battle

DaOur B-cells then learn to produce antibodies that quickly recognize those COVID-19 spikes

- The booster shot you get a few weeks later strengthens this memory
- If you were to actually get infected with COVID-19 in the future, your B-cells would recognize those tell-tale spikes
- Those smart B-cells would say, "This is a foreign invader we must destroy"
- They summon the rest of the immune system to attack the virus and protect us

- Note that many people will get a very sore arm, redness, swelling, aches, pains, fever for a few days after the vaccine
- This is actually the immune system learning to mount an attack. Think of it as a sign of the vaccine working
​_________________________________________________________________________
WHAT HAPPENED AFTER MY SHOT
Day #1: It has just been a few hours since my vaccine
I took some Tylenol and Advil to decrease my chances for the above side effects
If you get the vaccine (which I hope you do), ask your doctor before you consider taking Tylenol and/or Advil or Aleve

Day #2: Woke up with a sore upper arm muscle (deltoid) in the area of the shot. However, I expected this as usual with a good, strong vaccine.  I'll just take Tylenol plus Advil around the clock today to lower the risk of pain and to lower my risk of a flu-like syndrome reaction. 

Day #3: Mild, tolerable arm soreness. I feel great! I am optimistic about getting vaccinated and feeling safer.

A rheumatology researcher becomes a research study participant for the Pfizer COVID-19 vaccine

Dr. Kathryn Dao, a rheumatologist in Dallas, Texas, wrote about what it was like getting vaccinated for COVID-19 as a research study participant. I will include the link to her fascinating story below but will provide a short outline on some important points.

- It was Pfizer's placebo-controlled trial. How could she possible know she got the vaccine and not the placebo?
     ~ It is because she developed classic vaccine reaction symptoms after getting it
     ~ Out of interest, the name of the trial was: 
​
the phase 3 trial of the Pfizer/BioNTech mRNA vaccine against SARS-CoV2 (protocol C4591001) 

- How big was the research study and how long is it?
     ~ The goal was to get 44,193 subjects 
     ~ Subjects are expected to be followed for around 2 years each

- What were the Pfizer study results?
     ~ As of 11/13/20, 41,135 participants received their 2nd shot. Half got placebo, half got the vaccine.
     ~ There were 162 COVID infections in the placebo group
     ~ There were only 8 in the vaccine group!
     ~ The vaccine was 95% effective. This is just amazing!
     ~ The effectiveness was similar among different ages, genders, ethnicities/races.
   
- What were the side effects of the vaccine?
     ~ Fatigue in 4%
     ~ Headache in 2%
     ~ Side effects were more common in younger adults (note that this is similar to what happens with the Shingrix shingles shot: older people are less likely to get side effects)

Will I get the vaccine?

You better believe it! I will be 1st in line!
​
I will take both Tylenol and Aleve or Advil (Tylenol works through a different mechanism than Aleve and Advil do. Using them together theoretically may work better)
I'll advise my patients to do the same (for those who can safely take them)
CAUTION: Do NOT do this without asking your doctor first.

Dr. Thomas will be 1st in line to get the COVID-19 vaccine!

- I've had too many patients tell me about their relatives and loved ones who died from it ... spouses, siblings, parents, God-children, nieces, nephews, best friends

     ~ This is real, everyone! 
     ~ We need to have over 75% of us get vaccinated in order to achieve what is called "herd immunity"
     ~ Please do your part and get vaccinated. 
     ~ If you don't believe in protecting yourself with vaccines, change your mindset...

​Do it out of love for your loved ones. If you get vaccinated, you lower the chances of spreading it to your loved ones.

- Will I recommend it for my patients who have autoimmune disorders such as lupus, or those who are on immunosuppressant drugs?
     ~ Probably. However, I will go by what the expert recommended guidelines are.
     ~ One problem is that they probably did not include people with lupus and who are on drugs that suppress the immune system into the studies.
     ~ However, I suspect the experts will recommend it since all other non-live vaccines are safe for our patients, and this is not a live vaccine. 

Dr. Dao stated, "The relief was something I did not anticipate; it was a glimpse of the end of the pandemic. " She urged others to follow her footsteps and get the vaccine so we can end this pandemic and get back to a normal life.

Here is a link to Dr. Dao's very interesting personal account. It is a must read on RheumNow:
https://rheumnow.com/blog/my-experience-covid19-vaccine-trial-participant

Lupus patients are more likely to have allergies to antibiotics

​Many systemic lupus erythematosus (SLE) patients report numerous drug allergies. However, studies do not show an increased amount of allergies than non-lupus patients (other than antibiotics). SLE patients have higher rates of allergies and intolerances to penicillins, cephalosporins, sulfonamides, and the antibiotic erythromycin. The most important antibiotic intolerance is that of sulfonamide (often called “sulfa”) antibiotics. This most commonly refers to the antibiotic trimethoprim-sulfamethoxazole (Bactrim and Septra).

Sulfur versus sulfonamides versus other sulfa drugs and lupus

The element called sulfur exists in all of us, so none of us are allergic to sulfur. Many different molecules contain sulfur to include sulfates, sulfites, and sulfonamides. Lupus patients have an increased risk of antibiotic sulfonamides (specifically Bactrim, trimethoprim-sulfamethoxazole) flaring their lupus. Sulfonamide antibiotics are very different than sulfates, sulfites, and others. These are safe for lupus patients to take. There are some non-antibiotic sulfonamides (furosemide, hydrochlorothiazide, acetazolamide, sulfonylureas used for diabetes, and celecoxib). However, these do not appear to increase lupus flares and are safe for lupus patients to take (unless they just happen to have an allergy to that particular drug). 

Sulfa antibiotics can cause significant lupus flares (list is as an allergy!)

Around one-third of lupus (SLE) patients have reactions to Bactrim, and it can cause lupus flares as well. These reactions are more common in Caucasians, those with low lymphocyte counts (lymphopenia), and anti-SSA positive patients. Still, they can occur in any lupus patient. They especially can cause flares of fever, sun-sensitive rashes, and low blood cell counts. Sometimes these flares can be severe. There are so many other antibiotics now available that sulfonamide antibiotics can usually be avoided in SLE patients. 

I, and most lupus experts, recommend that all lupus patients always carry an up-to-date medication list (similar to the first image, above) and that it also includes an allergy list that includes “sulfa antibiotics.” This can protect you if you ever get sick and end up in the emergency room where it can be hard to remember to tell your entire medical history. While lupus patients are more likely to be intolerant of the antibiotics penicillin, cephalosporins, and erythromycin, these do not typically cause lupus flares, and the vast majority of SLE patients tolerate them well. Therefore, they do not need to be avoided in lupus patients who are not allergic to them.

Background of "The Lupus Secrets":

A long time ago, I realized that most patients and most physicians were not familiar with all the important things that lupus patients can do themselves that improve their health and lives. So, I made a list and called them “The Lupus Secrets" that addresses these important things. I called them "The Lupus Secrets" not because I wanted them to be a secret, but because they appeared to be a secret since most people (and doctors) did not know about all of them.

I regularly update this list as our knowledge of lupus improves. I give this list to all my patients, and encourage them to follow it. Most of my SLE patients are in remission or low disease activity, and I care for over 200 people who have SLE. I attribute my patients’ utilization of “The Lupus Secrets” as an important tool in achieving this goal. Please download a copy. Each recommendation has medical literature to back it up (check out the references below for this "Secret"), though each varies in the strength of evidence. 
​

References:
Petri, M, Allbritton, J. Antibiotic allergy in systemic lupus erythematosus: a case-control study. J Rheumatol 1992; 19: 265–269.​
​Wozniacka A, Sysa-Jedrzejowska A, Robak E, Samochocki Z, Zak-Prelich M. Allergic diseases, drug adverse reactions and total immunoglobulin E levels in lupus erythematosus patients. Mediators Inflamm. 2003;12(2):95-99. doi:10.1080/0962935031000097709

The interactions of hepatitis C and systemic lupus is strange, and hepatitis C can mimic lupus ... read on!

Hepatitis C is a virus that can attack the liver (called hepatitis) as well as numerous other organs of the body. Untreated hepatitis C infection can cause jaundice, cirrhosis, and liver cancer. However, the anti-viral drugs used to treat hepatitis C are miracle drugs, resulting in over 95% of infected individuals being cured with them.

The hepatitis C virus is most commonly transmitted through exposure to infected blood, most commonly by IV drug use, blood transfusions, and needles sticks. However, sexual contact, mother to fetus transmission, tattooing, and body piercing can also result in infections. The CDC recommends that all adults be tested for hepatitis C. In those with increased risk for infection (such as IV drug users), regular testing should be done. 

Drugs used to treat hepatitis C include: 
Glecaprevir, Grazoprevir, Paritaprevir, Simeprevir, Voxilaprevir, Daclatasvir, Elbasvir, Ledipasvir, Ombitasvir, Pibrentasvir, Velpatasvir, Sofosbuvir, and Dasabuvir. 

Hepatitis C can also cause the immune system to become overactive. Hepatitis C infection can look exactly like systemic lupus erythematosus (SLE). Hepatitis C infection can produce many of the same antibodies seen in SLE and cause many of the same problems, such as arthritis, rashes, vasculitis, kidney disease, and nerve problems. This is why rheumatologists usually test everyone that may have SLE for hepatitis C. Treating and curing the person of hepatitis C results in the lupus-like disease disappearing.

Since hepatitis C causes the immune system to become more active, if someone with SLE gets infected, their SLE can potentially become more active. Also, SLE patients have a higher chance of being infected with hepatitis C than the general population. This probably occurs due to their immune system, not being able to protect the person as well as it should. For unknown reasons, hepatitis B infections do not occur more commonly in SLE patients. All SLE adults should get tested for hepatitis C and undergo treatment if positive for an active infection. 

- Don Thomas, MD

​Reference: Mahroum N, Hejly A, Tiosano S, et al. Chronic hepatitis C viral infection among SLE patients: the significance of coexistence. Immunol Res. 2017;65(2):477-481. doi:10.1007/s12026-016-8886-7

Photo credit = Wikipedia and ​Blausen Medical Communications, Inc

That is right!
Many of you reading this post should get the hepatitis B vaccine

Less commonly known reasons for getting a Hep B vaccine include:

- Diabetics aged 19 through 59 who have not been vaccinated!
- Anyone with fatty liver disease
- An ALT or AST (liver blood tests) greater than twice the upper limits

Read the below link to learn why these groups should get a hepatitis B vaccine per the CDC

Here is the CDC's rationale for these groups getting vaccinated as well as a list of other at risk individuals who should get vaccinated: 
​
https://www.cdc.gov/hepatitis/hbv/bfaq.htm​

Many of you reading this should get it based upon this and you (and possibly even your doctor) did not know.

Get your hepatitis B vaccine

- Don Thomas, MD

Photo shows a man with jaundice (note the yellow eyes) due to hepatitis. (photo credit = CDC)

​Mahroum N, Hejly A, Tiosano S, et al. Chronic hepatitis C viral infection among SLE patients: the significance of coexistence. Immunol Res. 2017;65(2):477-481. doi:10.1007/s12026-016-8886-7

Question of the day: Dr. Thomas, I have lupus and was told by another lupus patient that she gets a flare when she gets a flu shot. Do flu shots cause lupus flares?  - JP

ANSWER: "No and Yes; in that order"

Fortunately, the vast majority of systemic lupus erythematosus (SLE) patients do not get a flare after getting the flu shot. A recent study showed that only 32 SLE patients out of 1966 (1.6%) who got the flu shot (influenza vaccine) had flares from their SLE, and all were mild. I have never had a patient get a severe flare from the flu shot over 30 years. I had one severe flare from Pneumovax, though.

Now the really interesting thing about this study is as follows... it would be very easy to conclude "the flu shot must cause flares in 1.6% of SLE patients." However, that is not true. Imagine studying 1966 SLE patients even for just a very short period of time. I find it amazing that only 32 out of 1966 would flare. You'd expect more of them to flare during the study period simply because that is what lupus likes to do.

Compared to healthy controls, they responded very well to the vaccine as far as it protecting them from the flu.

It is flu season. Please get your flu shot. Especially with COVID-19, we do not want a one-two punch!

NOTE: The Centers for Disease Control recommends getting the flu shot BEFORE the end of October.

(Many people misinterpret this as they should get it in October). Their only warning about this is that elderly vaccine recipients may have the vaccine response be a little weaker at the end of the flu season if they get it in July or August. Otherwise, it is best to get it as soon as it is available to help decrease community spread.

Please SHARE my post with others.

Click the COMMENTS button above regarding your experience with the flu shot when you have lupus. Would love to hear from people who have had no problems at all and those who have. 

- by Don Thomas, MD, FACP, FACR

It's that time of year again. Time to get your flu shot! I already got mine, have you gotten yours.  Here are some important facts about the flu shot, infections, and systemic lupus erythematosus (SLE):

- Infections are the 3rd most common cause of death in SLE and most are preventable with measures such as vaccines. Learn of the importance of preventing infections in Dr. Thomas' Lupus Secrets
- The 2018 - 2019 flu season caused close to 60,000 flu-related hospitalizations in the United States. 
- Fortunately, with the public practicing social distancing, hand-washing, mask-wearing, etc. due to COVID-19, hopefully we'll see less influenza. However, we still need everyone to get the flu shot. Getting COVID-19 plus influenza would be deadly.
- The flu shot reduces the risk of getting the flu by 50%, but if you get it, you are more likely to have a less severe infection as per the below ...
- People who get the flu shot are 82% less likely to end up in the intensive care unit. SLE patients are 60% less likely to die compared to people with SLE who do not get vaccinated. 
- The flu shot has never given anyone the flu = Fact! 
- The flu shot does not cause autism. 
- You should still get the flu shot, even if you have an egg allergy.
- You can get the flu shot on any of your lupus medications. However, prednisone greater than 40 mg a day will decrease your response to the vaccine. If you are on Rituxan, try to get it 4 weeks before your Rituxan dose. 
- If you do not believe in getting the flu shot (shame on you), at least get it to protect the ones you love. This is one of the main reasons why we health care professionals get it. We want to lower the chances of spreading it to our patients. 

Please get your flu shot. The life you save may be your own.

- Don Thomas, MD