Vaccine Hesitancy: Wariness Is Rare, But There’s a Wider Worry About COVID Vaccines’ Efficacy in Some Populations

Patients’ concerns may be well founded, according to recent data. Dr. Paik is one of the co-authors of a new study of 123 patients with rheumatic diseases who were tested for COVID-19 antibodies at baseline and prior to their second mRNA vaccine dose between Jan. 8 and Feb. 12, 2021. Their preliminary data, shared in a letter to Annals of the Rheumatic Diseases, showed that patients on rituximab and mycophenolate regimens were less likely to have an antibody response, while those on methotrexate and tumor necrosis factor (TNF) inhibitors had detectable antibodies.⁴

In another preprint study of 133 patients with chronic inflammatory diseases on various immunosuppressive therapies, those on B cell-depletion regimens had a 36-fold reduction in vaccine antibody response, and patients on glucocorticoids had a 10-fold reduction. In this study, Dr. Kim and his colleagues found that patients treated with immunosuppressive therapies—jakinibs and antimetabolites, including methotrexate—exhibit impaired SARS-CoV-2 vaccine-induced immunity, with glucocorticoids and B cell depletion therapy more severely impeding optimal responses.⁵ Other targeted therapies, such as TNF, interleukin (IL) 12, IL-23 and integrin inhibitors, had only modest impacts on antibody formation and neutralization.

According to the ACR guidance, to optimize vaccine response, rheumatologists may advise patients on the following therapies to hold their medications for a short time after their vaccines if they have stable disease:²

• Mycophenolate: Hold for one week after each vaccine dose.
• Methotrexate: Hold for one week after each mRNA vaccine dose and for two weeks after a single-dose vaccine.
• Jakinibs: Hold for one week after each vaccine dose.
• Abatacept SQ: Hold for one week prior to and one week after the first vaccine dose only.
• Abatacept IV: Time the vaccine to occur four weeks after completed abatacept infusion and postpone next infusion for one week after the first vaccine dose.
• Cyclophosphamide IV: Schedule infusion for one week after each vaccine dose if possible.
• Rituximab: If a patient’s COVID-19 risk is low or they can mitigate risk with preventive measures, try to schedule each vaccine dose four weeks before the start of the next rituximab cycle, and then hold rituximab for two to four weeks after final vaccine dose if disease activity allows.
• Acetaminophen and NSAIDs: Hold for 24 hours before vaccination.

“In my patients on mycophenolate, I suggest we hold their medication for one week after their vaccine. We believe that by holding such immunosuppressants, the response may be better,” says Dr. Paik.

Dr. Kim stresses to his hesitant patients that because COVID-19 is more severe and deadly in some immunosuppressed patients, and the safety of vaccination appears to be excellent for immunosuppressed patients, he strongly recommends vaccination for them.