To help people understand what this means for those with these diseases, the American College of Rheumatology has again updated its clinical guidance for physicians.
People with RA have many questions about the COVID-19 vaccine, and especially about this newly added dose. To get answers to common questions, we spoke with Juan J. Maya-Villamizar, MD, a rheumatologist at the Rheumatology Centre of Palm Beach, in Lake Worth, Florida, and a medical adviser to the digital arthritis community CreakyJoints.
Everyday Health: Does the CDC’s recommendation that people who are immunocompromised get a third shot of their mRNA vaccines apply to everyone with rheumatoid arthritis?
Dr. Juan Maya-Villamizar: It isn’t the fact that people have an autoimmune condition like RA that is the issue, but rather that people with these diseases generally take immunosuppressive drugs. The need for the third shot covers people on most of the medications we use for RA with the exception of the drug hydroxychloroquine.
Some medications that trigger the need for a third dose include steroids, tumour necrosis factor inhibitors (TNFi), interleukin-6 inhibitors (IL-6), methotrexate, sulfasalazine, leflunomide, azathioprine, mycophenolate, and Janus kinase (JAK) inhibitors. People who are not on immunosuppressive drugs because they have low disease activity or who are only on hydroxychloroquine are not part of this group.
EH: Why will people on these meds benefit from that third shot?
JMV: The data so far are preliminary, but what it has shown is that antibodies against COVID-19 are often not generated after the second dose. In some studies, up to 50 percent of patients who are on an immunosuppressive medication did not make antibodies. By getting the third dose, the number of people who finally develop antibodies goes up. Even so, not everyone will make them.
EH: The CDC is not calling this a booster, but rather a third shot in the series. Why are they making that distinction?
JMV: They want to clarify that a booster is when someone gets an antibody response but then it starts fading, and the next shot is to regain the response. Here they are saying the third shot is part of the series of vaccines needed to create the response in the first place. Also, it emphasizes how important this third shot is for immunocompromised people in order to make the immunization effective.
EH: When should a person get the third dose?
JMV: The recommendation is to get the shot at least four weeks after the second shot of your Pfizer or Moderna vaccine. If possible, you should stick with the same one you had before. So if you had Moderna for your first two shots, you should try to get that for your third. The implication of the CDC’s words “if possible” is if you’re not able to get the same vaccine for some reason, you can get the other mRNA vaccine.
So far there is no official recommendation about another shot for people who initially got the Johnson & Johnson vaccine, but we expect that to be coming.
EH: Are there risks to getting an additional shot?
JMV: For immunocompromised patients there have not been any risks reported, other than reactions that are expected for any vaccine: localized arm pain or reactions, or symptoms like you get with a cold such as muscle aches, fever, or chills. If you had a reaction to your prior shots that doesn’t mean you will have one after the third shot, but it is possible.
People with RA may also get a little flare of joint pain. The recommendation is to use your typical medications, such as acetaminophen, ibuprofen, or Aleve. Be sure to talk to your rheumatologist if you feel you’re having a severe joint pain reaction.
Of course, with any type of intervention there is always a very small percentage of unexpected reactions. If something comes up that concerns you after you get the third shot, speak to your doctor.
EH: The American College of Rheumatology recommends that people briefly shift the timing of some of their medications when they get the first or second shot if their disease is stable. For example, they suggest that JAK inhibitors should be delayed for a week after each COVID-19 vaccine dose. Do these same recommendations apply for the third shot, too?
JMV: The task force agreed that certain medicines should again be held for one to two weeks around the vaccine, such as mycophenolate and JAK inhibitors. But they did not reach consensus about shifting medications around the third shot for many medicines, including steroids and most biologics. I myself am telling my patients whose disease is stable to follow the same recommendations as for the other shots, since this may help improve response to the vaccine. Everyone should talk to their doctor about their own treatment situation.
EH: Are there other things people with a rheumatic disease should know about the vaccines?
JMV: Without question everyone should get vaccinated. Recent data show that most hospital admissions for COVID-19 are in unvaccinated patients. It’s clear that getting vaccinated decreases your risk of a hospital admission and prevents you from getting stronger forms of the disease. Staying out of the hospital has additional benefits for immunocompromised people because of all the other infections that live there.
If you have specific concerns that are holding you back from being vaccinated, be sure to share them with your doctor.
Even after you get the three shots, it’s still important for people who are immunocompromised to diligently follow other COVID-19 prevention measures, such as wearing a mask; avoiding large gatherings, especially in poorly ventilated spaces; and maintaining at least six feet of distance from other people.
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