COVID-19 vaccine boosters 'likely' needed for immunosuppressed population
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Patients who are immunosuppressed will “likely” need regular COVID-19 vaccine boosters in the future, according to Jeffrey R. Curtis, MD, MS, MPH, chair of the American College of Rheumatology COVID-19 Vaccine Clinical Guidance Task Force.
Curtis, a rheumatologist, epidemiologist and professor of medicine at the University of Alabama at Birmingham, told attendees at a recent Q&A hosted by the Rheumatology Research Foundation that, in his opinion, COVID-19 vaccine boosters could potentially become common among certain patients.
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“Of course, there is a lot of science and the science is very much in evolution. Whatever you think you know this month, may well be different next month, so for that reason I think everything we say or talk about tonight is subject to change,” Curtis told attendees at the virtual forum. “I personally think that it is likely that people will need a booster. That may not be everybody, but I think that getting a booster dose and then having some periodicity to this is likely to be quite common. This may end up being more or less like the flu shot, where you need it if not annually, then at least with some regularity.”
He added that it’s also possible that, depending on what treatments a patient is receiving, individuals may be more likely to benefit from a booster or even a repeat of the vaccine series.
“Someone in the chat brought up the circumstance where they got a dose or a vaccine that maybe wasn’t what they were hoping to get, and so, depending upon what treatments you’re on, this is something to talk with your provider about,” Curtis said. “But I very much think the concept of a booster is likely to have traction.”
Asked about the prospect of patients “mixing” the Pfizer or Moderna vaccine series with a booster from the other company, Curtis responded that he expects experts to recommend people to remain with the source as their initial vaccine.
“Likely that will not be a combination studied in the very near future,” he said. “I would have every expectation that you should stick with the booster of the one that you got in the first place.”
Rituximab, mycophenolate may impact vaccine response
Curtis also commented on certain rheumatic drugs that may have the potential to reduce the effectiveness of the COVID-19 vaccine, including rituximab (Rituxan, Genentech) and mycophenolate.
“Rituximab would be, I think, one of the more concerning ones,” he said. “Rituximab is very effective at depleting B cells and making it hard for the body to create antibodies. That is a good thing when you’re treating something that has antibodies that you’re trying to get rid of, but maybe not so good of a thing if you’re trying to help the immune system fight off an infection in the future.”
“Rituximab likely diminishes the immune response greater than many other treatments. Mycophenolate is another one,” he added. “Those are the two that I would probably have the greatest pause about being at all confident that someone was well protected against COVID-19.”
According to Curtis, concerns have also been raised, including by those on the ACR COVID-19 Vaccine Clinical Guidance Task Force, regarding JAK inhibitors and reduced vaccine response.
“That’s why there was a recommendation for some of them that it might be prudent to hold therapy for a brief period of time if that’s possible,” Curtis said. “That’s not a general admonition that you should do it at all costs, but something to talk with your rheumatologist about. The ACR has very up to date recommendation from this guidance task force that are current literally within the last couple of days.”
Do not delay the second dose
A recent study published in Gut found a reduced immune response to the COVID-19 vaccine immediately following the first dose among patients with inflammatory bowel disease receiving infliximab (Remicade, Janssen). However, when the same patients later received their second dose, the immune response appeared normal.
According to Curtis, this suggests an issue for patients — not just with IBD and infliximab, but a host of autoimmune diseases and treatments — in countries that have extended the time frame for receiving the second dose for dose-sparing purposes.
“If you did live in a country — and the United States is not, so much, one of them — that is extending the interval from the first to the second dose in order to spare doses, so that everybody would get the first dose, I think that’s probably not a great idea for someone who is on immunomodulatory therapies with Crohn’s disease or lupus, or vasculitis, or rheumatoid arthritis, or anything,” Curtis. “In fact, it’s not just infliximab, which is Remicade and [the biosimilars] Inflectra and Renflexis. I also suspect that it’s true of quite a number of our drugs.”
He added that there are now several studies looking into COVID-19 vaccine response after the first and second doses in patients with autoimmune diseases, with results suggesting that full antibody response is developed only after the full series is completed.
“There’s now a handful of studies in the literature where they’ve looked at what happens after you get the first dose,” Curtis said. “Vaccine response for many is OK, but for quite a number it’s not great. So, I think that the main take-home message that I’ve learned from several of those manuscripts that I’ve reviewed, both in the public domain and that a few sent to me confidentially, you really should get that second dose.
“This is especially true if you have an autoimmune condition or you’re on immune-affecting therapies, because, unless you’ve completed the whole series as intended, some people are going to remain at risk and not mount the expected antibody response until they get the second dose,” he added. “Then, by and large, after they get the second dose, rheumatology patients appear to be well protected, with a couple of exceptions.”
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Curtis J. Patient Webinar: COVID-19 Vaccines and Treatments. Presented at: Rheumatology Research Foundation. May 11, 2021 (virtual Q&A).
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