Table 4.
Guidance related to the use and timing of immunomodulatory therapies in relation to COVID‐19 vaccination administration in RMD patients*
| Medication(s) | Timing considerations for immunomodulatory therapy and vaccination | Level of task force consensus |
|---|---|---|
| Abatacept (IV) | Time vaccination to occur 1 week prior to the next dose of abatacept (IV). | Moderate |
| Abatacept (SC) | Withhold for 1–2 weeks (as disease activity allows) after each COVID‐19 vaccine dose. | Moderate |
| Acetaminophen, NSAIDs | Assuming that disease is stable, withhold for 24 hours prior to vaccination. No restrictions on use postvaccination if symptoms develop. | Moderate |
| Belimumab (SC) | Withhold for 1–2 weeks (as disease activity allows) after each COVID‐19 vaccine dose. | Moderate |
| TNFi, IL‐6R, IL‐1Ra, IL‐17, IL‐12/23, IL‐23, and other cytokine inhibitors † | The task force failed to reach consensus on whether or not to temporarily interrupt these following each COVID‐19 vaccine dose, including both primary vaccination and supplemental/booster dosing. | Moderate |
| Cyclophosphamide (IV) | Time cyclophosphamide administration so that it will occur ~1 week after each vaccine dose, when feasible. | Moderate |
| Hydroxychloroquine | No modifications to either immunomodulatory therapy or vaccination timing. | Strong |
| Rituximab or other anti‐CD20 B cell–depleting agents | Discuss the optimal timing of dosing and vaccination with rheumatology provider before proceeding. ‡ | Moderate |
| All other conventional and targeted immunomodulatory or immunosuppressive medications (e.g., JAK inhibitors, MMF) except for those listed above § | Withhold for 1–2 weeks (as disease activity allows) after each COVID‐19 vaccine dose. | Moderate |
This guidance applies to both primary vaccination and supplemental/booster dosing. Boldface text indicates updates that were added to the version 4 summary document at the end of 2021. For details on the history of updates to these guidance statements, see Supplementary Table 6, on the Arthritis & Rheumatology website at http://onlinelibrary.wiley.com/doi/10.1002/art.42109. RMD = rheumatic and musculoskeletal disease; IV = intravenous; SC = subcutaneous; NSAIDs = nonsteroidal antiinflammatory drugs; TNFi = tumor necrosis factor inhibitor.
Examples of cytokine inhibitors include the following: for interleukin‐6 receptor (IL‐6R), sarilumab and tocilizumab; for IL‐1 receptor antagonist (IL‐1Ra), anakinra and canakinumab; for IL‐17, ixekizumab and secukinumab; for IL‐12/IL‐23, ustekinumab; for IL‐23, guselkumab and rizankizumab.
Some practitioners measure CD19 B cells as a tool with which to time the booster and subsequent rituximab dosing. For those who elect to dose without such information, or for whom such measurement is not available or feasible, a supplemental vaccine dose 2–4 weeks should be provided before next anticipated rituximab dose (e.g., at month 5.0 or 5.5 in patients being administered rituximab every 6 months).
Includes apremilast, azathioprine, calcineurin inhibitors, cyclophosphamide (oral), IV immunoglobulin, leflunomide, methotrexate, JAK inhibitors (tofacitinib, upadacitinib, baricitinib), mycophenolate mofetil (MMF), and sulfasalazine.