Should we vaccinate high risk rheumatic disease with third booster dose?

A COVID-19 booster is an extra dose of vaccine given after the protection from the first injection (s) wears off over time. After immunity from the original dose(s) starts to diminish, a booster shot will be generally given. The booster is intended to help people maintain their immunity for a longer period of time.

The third dose of the Pfizer or Moderna mRNA COVID-19 vaccines is identical to the first two doses. It may help protect those with compromised immune systems who did not have enough reaction to initial doses of the mRNA vaccines.

The recommend minimum gap between the second and third booster dose is 28 days. The CDC recommends the administration of the third dose of the FDA-approved COVID-19 vaccine to subjects with certain medical conditions that compromise the immune system.

When the time between shots is increased, the immune response is enhanced more than threefold. The amount of anti-spike protein antibody response is found to be increased with a longer gap between the two doses.

According to Padmanabha Shenoy, one of the most renowned clinical immunologists and rheumatologists who conducted the study, two doses of vaccination given at a longer interval are expected to provide better and longer-lasting immunity against COVID-19.

Yes, The American College of Rheumatology (ACR) has amended its COVID-19 vaccine clinical guidance for rheumatoid arthritis patients, recommending the third dose of the mRNA vaccine for individuals on immunosuppressive or immunomodulatory medication.

The changes come after the CDC recently recommended that some immunocompromised individuals get a third dosage of Pfizer or Moderna’s COVID-19 mRNA vaccine.

The new ACR recommendations include advice on when to give the third dose, a preference for mRNA vaccines in patients who have not been vaccinated, and a mention of the FDA’s emergency use authorization (EUA) for post-exposure prophylaxis with monoclonal antibody treatment among COVID-19-exposed patients, including most vaccinated rheumatoid arthritis patients.

The ACR’s new information addresses the concerns on booster vaccination and other practical challenges that rheumatologists and patients are dealing with, as a result of the epidemic.

According to Jeffrey Curtis, a professor of medicine at the University of Alabama in Birmingham’s Division of Clinical Immunology and Rheumatology, based on the disease activity, clinicians should advise patients to wait for 1 to 2 weeks after the booster dose before receiving certain immunomodulatory or immunosuppressive medicines. The exceptions to this rule are glucocorticoids and anti-cytokine therapies, as well as most biologic drugs.

The ACR task group did not comment on the temporary discontinuation of anti-cytokine drugs like TNF inhibitors and others like interleukin-17, IL-12/23, IL-23, IL-1R, and IL-6R antagonists considering the effective vaccine response to the point where they should be temporarily stopped.

As a result, none of the existing recommendations address whether these therapies should be temporarily suspended or continued at the time of booster vaccination.

Before obtaining a third dosage of the COVID-19 vaccine, patients who are receiving other anti-CD20 drugs should take the doctor’s opinion about the best timing.

According to the press release, some doctors are measuring CD19-B cells in order to schedule the booster and subsequent rituximab doses. The ACR recommends delivering the third dosage 2 to 4 weeks before the next expected rituximab dose to patients in whom such details are not accessible.

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