COVID Vaccine for Immunocompromised Patients and What Drugs to Stop

The American College of Rheumatology Provides Guidance for stopping drugs to enhance the COVID vaccine for immunocompromised patients

Coronavirus vaccine for COVID-19 and lupus patients
COVID-19 vaccine: Please get yours!
Revised 9/6/21 with new drugs to stop for vaccines per revised ACR recommendations

How should we deal with immunosuppressants and the COVID vaccine for immunocompromised patients? In 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.

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)
– 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)

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

Drug recommendations summary:

On their August 2021 revision of the guidelines, they stated that “Except for glucocorticoids and anti-cytokine therapies (see footnote), hold all immunomodulatory or immunosuppressive medications for 1-2 weeks after booster vaccination, assuming disease activity allows.” for supplemental dosing (e.g. booster doses. 
Yet, they did not change their recommendations for initial COVID vaccines.
This presents some questions.
Why is it not recommended to stop some of these same drugs (such as azathioprine) for the initial dosing? It seems it would be just as important to do so.
Also, hydroxychloroquine is an “immunomodulatory,” yet there is not good evidence that it prevents vaccines from working.

What I am doing in my practice regarding immunosuppressants and vaccines to include COVID vaccines in immunocompromised patients :

Recommend that my patients stop immunosuppressants for 2 weeks after all vaccines in order to hopefully have them work better. Some drugs, such as rituximab, mycophenolate, and abatacept: I will go by the recommendations higher up in the chart, unless the ACR committee changes their recommendations based upon better medical evidence.
Do not do this on your own without talking to your doctor.

Other important recommendations from the ACR:

– 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.

Author

Don Thomas, author of “The Lupus Encyclopedia” and “The Lupus Secrets

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