Nearly one-third of rheumatology drug regimens shifted at time of COVID-19 vaccination
As many as 27.9% of immunomodulatory or immunosuppressive regimens were changed around the time of COVID-19 vaccination, with patients responsible for most modifications, according to data published in The Lancet Rheumatology.
“Due to concerns about underlying immune dysregulation and immunosuppression, patients with systemic rheumatic diseases might modify their medications at the time of COVID-19 vaccination to optimize their immune response and mitigate vaccine side-effects,” Medha Barbhaiya, MD, MPH, of the Hospital for Special Surgery, in New York, and colleagues wrote.
“Immunosuppressed patients in New York state were approved for vaccination on Feb. 15, 2021, soon after the American College of Rheumatology COVID-19 Vaccine Clinical Guidance Task Force issued its first management guidelines on Feb. 8, 2021,” they added. “Whether real-world behavior was aligned with these guidelines is unknown.”
To examine treatment changes at the time of COVID-19 vaccination among patients with rheumatic disease, Barbhaiya and colleagues emailed secure web-based surveys to 7,505 individuals who had been seen at least once at a large rheumatology center in New York between April 1, 2018, and April 21, 2020.
The survey collected data on immunomodulatory and immunosuppressive medications at COVID-19 vaccination, including information on whether doses were taken earlier than scheduled, delayed or skipped altogether. Respondents were also asked who initiated the change — either a rheumatologist, another clinician or themselves.
Among the 2,753 individuals who responded to the survey as of March, a total of 1,852 reported receiving at least one vaccine dose and provided complete answers to the medication modification questions, and were thus included in the current analysis.
According to the researchers, there were 1,373 individual reports of immunomodulatory or corticosteroid use at the time of the first vaccine dose. Prior to the first vaccine dose, 15.7% of medication schedules were modified. Among, these, 41 — or 19.1% — of medications were taken earlier than scheduled while 174 — or 80.9% — were delayed or skipped.
Modified medications included biologics, conventional synthetic disease-modifying antirheumatic drugs, hydroxychloroquine, corticosteroids and small molecules. Among these categories, TNF inhibitors — at 22.8% — and methotrexate — at 26.5% — were most commonly altered, and were more likely to be delayed or skipped around COVID-19 vaccination, rather than taken early. Patients and physicians were about equally responsible for modifications at the first vaccine dose.
At the second dose, 27.9% of 899 treatment regimens were altered. Among these medication changes, 41.8% were delayed or skipped between the first and second vaccine dose, 16.3% were taken earlier than scheduled, and 41.8% were delayed or skipped following the second vaccine dose. TNF inhibitors accounted for 16.3% of alterations while MTX represented 33.5% of the changes around the second vaccine dose.
Patients were responsible for 49.4% of modifications at the second dose, compared with 46.2% being recommended by a rheumatologist and 4.4% by another physician. Among immunosuppressive or immunomodulatory medications taken early prior to the second vaccine dose, 73.2% were initiated by patients. Meanwhile, rheumatologists were responsible for 52.4% of treatments that were delayed or skipped following the second vaccine dose.
“We were surprised by the finding that many of the medication modifications around the COVID-19 vaccine were patient-directed, and not under the guidance of their rheumatologist,” Barbhaiya told Healio Rheumatology. “Some medication modifications, such as those related to modifying methotrexate dosing schedules prior to either vaccine dose, or any modifications related to TNF inhibitors or hydroxychloroquine, were not consistent with best practices as advised by the American College of Rheumatology task force.”
She added: “Although the role of medication modifications at the time of COVID-19 vaccination and subsequent rheumatic disease flare-ups is still being studied, during the ongoing pandemic, rheumatologists may play a critical role in disseminating updated evidence-based guidance in real time to patients regarding future COVID-19 vaccine doses.”