Rheumatoid arthritis seen on an x-ray of the hand. (Photo by: BSIP/Universal Images Group via Getty ... [+]
Since autoimmune diseases are so common in women, I’ve long waited to see if there were specific recommendations for Covid-19 vaccinations in patients with these underlying family of illnesses. The answer is “no.” Unfortunately, this is based on hunches and physicians’ experiences, rather than solid data. The American College of Rheumatology (ACR) just released their recommendation: “Although there is limited data from large population-based studies, it appears that patients with autoimmune and inflammatory conditions are at a higher risk for developing hospitalized COVID-19 compared to the general population and have worse outcomes associated with infection,” said Dr. Jeffrey Curtis, chair of the ACR COVID-19 Vaccine Clinical Guidance Task Force. “Based on this concern, the benefit of COVID-19 vaccination outweighs any small, possible risks for new autoimmune reactions or disease flare after vaccination.”
With Covid-19, we’ve seen that Blacks, Latinos, and Indigenous people (BIPOC) have had worse outcomes. They have higher rates of illness and death. Much of this is likely related to income, poorer living conditions, and access to health care, aka “social determinants of health.” When we think of disparities, we often focus on race and income, rightly so. Some diseases also affect women much more than men, and these tend to get short shrift.
In autoimmune diseases, your body has an overactive immune system and attacks itself. This family of illnesses includes SLE (systemic lupus erythematosus), rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease, and Type 1 diabetes, among many others. We don’t know why this happens. Some illnesses seem to be triggered by infection. We do know that it can run in families and that a person with one autoimmune disease is likely to develop others.
Estimates of the prevalence vary greatly and range from 3% [4.6%] to about 8% of people in the US having autoimmune illnesses—or at least 10 million people. It ranks fifth, after obesity, cardiovascular disease, Type 2 diabetes, and cancer.
Strikingly, almost 80% of autoimmune diseases occur in women. Many have fluctuating symptoms and, as with other rare diseases, can take years to be diagnosed. Because they can mimic other illnesses—or perhaps because women’s symptoms may not be taken as seriously as men’s—patients “average seeing six doctors over four years” before diagnosis. Sometimes this was as much as ten years.
Famous celebrities with lupus include Selena Gomez, Toni Braxton, Flannery O'Connor, J. Dilla, musician Seal, and actor Ray Walston. Others with rheumatoid arthritis include tennis star Danielle Collins, quarterback Terry Bradshaw, Rosalind Russell, Lucille Ball, and James Coburn.
What do we know about Covid in patients with autoimmune diseases?
The news here is again conflicting. One small study found no difference in hospitalization rates. Another found a higher risk of death in those on steroids >10 mg per day.
“Some studies found higher odds of respiratory failure requiring mechanical ventilation in patients with rheumatic and musculoskeletal diseases than in the general population.” Others did not. Yet another found higher risks for kidney failure and blood clots.
It’s a double whammy if you are a BIPOC with autoimmune disease and fall ill with Covid-19. Blacks had a 2.7-fold increased risk of requiring hospitalization (1.98 for Hispanics) than whites, and both had a three times increased risk of needing mechanical ventilation.
Special vaccine considerations
The consensus opinion is that patients with autoimmune diseases are far safer getting the Covid vaccine than not. These vaccines do not contain live virus. It just contains a fragment of mRNA, or messenger RNA. This directs your cells to make a specific “spike” protein so that you will mount an antibody response to the actual virus.
Unfortunately, both the Pfizer and Moderna trials excluded volunteers on immunosuppressive therapy. I have not seen any data on subgroups regarding side effects for those with autoimmune disease. We do know that women tend to mount a stronger immune response to vaccines. Absurdly, data on the response and adverse reactions to Covid-19 vaccine appears not to have been even reported by sex.
For now, the main consideration for patients with autoimmune or rheumatologic diseases is the timing of the vaccine. The primary recommendation from the ACR is to delay certain medications for one week after vaccination. These include
- methotrexate
- janus kinase (JAK) inhibitors - baricitinib (Olumiant), tofacitinib (Xeljanz), upadacitinib (Rinvoq)
- Cyclophosphamide
Longer delays are recommended for biologics - abatacept (Orencia), rituximab (Rituxan)
Having an underlying condition that puts you at increased risk does not necessarily boost your chance of receiving a vaccine any time soon. It puts you in CDC category 1C, after the elderly and essential workers in most states.
The bottom line—too little information has been shared to make sound, scientific and data-based decisions about Covid vaccines in patients with autoimmune diseases. The Pfizer and Moderna vaccines (and others in the pipeline) have thus far been remarkably safe and effective. Based on experience with Covid and with other vaccines, it seems far better for people with autoimmune diseases to take these vaccines, than to risk Covid.
