Drug holiday boosts rheuma patient covid vax success: latest ACR update

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The ACR-APLAR session featured talks on ‘Known knowns and known unknowns’ about covid vax, progress in PsA and racial differences in systemic sclerosis.

The ACR – APLAR session featured talks from Jeffrey Curtis on ‘Known knowns and known unknowns’ about covid vax, Philip Mease on progress in PsA and Lorinda Chung on racial differences in systemic sclerosis.

Get a booster and hold immunology therapies were some of the latest covid-19 vaccination updates presented at this week’s APLAR Congress by Professor Jeffrey Curtis, head of American College of Rheumatology covid-19 vaccine task force.

In his presentation ‘Known knowns, and known unknowns, about covid-19 vaccination in rheumatic disease patients’, Professor Curtis confirmed that the effect of holding back medications was still unknown. But the ACR still recommended holding drug treatment for one to two weeks for most immunomodulators if the disease was well controlled or at least stable.

Professor Curtis advised that this was new information since the previous ACR update about vaccination timing for drug therapies on 4 August. The new guidelines suggested that drug therapy be held for an additional nine drug types, including JAK inhibitors and mycophenolate.

The ACR covid-19 vaccine task force that developed the new guidelines included rheumatologists, infectious disease specialists and public health experts from the Centers for Disease Control and Prevention (CDC). In the absence of sufficient covid vaccine evidence, Professor Curtis said that the taskforce developed the guidelines after considering “a great body of evidence about immunomodulatory therapy for other vaccines and applied those principles to covid-19 vaccination.”

One of the more influential studies, Professor Curtis said, was the study out of Korea, where patients with rheumatoid arthritis responded to influenza vaccination with higher antigens if they held methotrexate for two weeks following vaccination.

Professor Curtis cited other studies, still in pre-print, that indicate covid vaccination is blunted by some drugs including mycophenolate, rituximab and possibly JAK inhibitors. “So that’s not that dissimilar, frankly, to what we see with the other vaccines, influenza, pneumococcal,” he said.

“A fairly high proportion of rheumatology patients have undetectable antibodies after the first dose of covid-19 vaccination,” Professor Curtis said. At least two vaccine doses and a booster were recommended

The ACR guidelines differed somewhat to the Australian Living Guidelines which recommended to not interrupt the majority of drug therapies for covid-19 vaccinations. The Australian Rheumatology Association has previously stated that they recommend Australian clinicians refer to the domestic guidelines. These guidelines were last updated on 25 June.

Professor Curtis also said that ACR guidelines suggested rheumatologists should not encourage patients to go beyond public health orders on social distancing. This could induce unreasonable covid-related fear in patients, he said. “It’s not going to be a helpful strategy to avoid things that might reduce employment or social interaction.” 

Also featured at the ACR – APLAR session was research into racial differences in systemic sclerosis phenotype, presented by Professor Lorinda Chung from Stanford University School of Medicine.

Many studies suggest that people from Asian and Black racial groups have onset of systemic sclerosis at an earlier age, high prevalence of lung disease and higher mortality rates, Professor Chung said. Rheumatologists should therefore consider close follow-up for Asian and Black patients who present with Raynaud’s phenomenon or undifferentiated connective tissue disease in order to capture systemic sclerosis onset.

“Once the diagnosis of systemic sclerosis is clear,” she told Rheumatology Republic after the conference, “early and regular screening for lung disease, and potentially earlier and more aggressive treatment, should be considered for Blacks and Asians.”

The progress of drug therapies for psoriatic arthritis was also presented. Professor Philip Mease, director of rheumatology at the Swedish Medical Centre in Washington, summarised head-to-head trial data between various medications. He also touched on the impact of gut microbiota in the development of psoriatic arthritis, and the latest treatment guidelines from Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

Wrapping up his presentation on a high note, Professor Mease said, “This is a good time for treatment of psoriatic arthritis.

“Our patients have a number of different medications to choose from and to move onto, if they lose effect or have safety issues with current medications, as we try to achieve a goal of remission or low disease activity.”

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