Study finds the benefit of fourth dose COVID-19 vaccination in autoimmune rheumatic diseases patients

The findings of a nationwide retrospective analysis published in Rheumatology reported that patients with an autoimmune rheumatic disease (ARDs) who received a fourth dosage of the BNT162b2 COVID-19 vaccine seem to be better protected than patients who received three doses.

Dr. Amir Bieber and co-researchers evaluated the effects of the fourth dose of COVID-19 vaccination using BNT162b2 COVID-19  in patients with ARDs. They found that the fourth dose was linked to a lower risk of COVID-19 infection than the controls. Out of 43,748 recruited patients with ARDs, 27,766 and 15,982 belonged to the control and fourth vaccination groups, respectively. About 25% of the control group and 11% of the fourth dosage group contracted COVID-19, respectively (P <0.001). Regardless of the baseline characteristics or medical treatment, patients who received the fourth dose had a reduced risk of COVID-19 infection than the overall cohort (HR 0.54) and throughout every subgroup, except for rituximab. A similar association was noted for the risk of COVID-19-related hospitalization (HR 0.36) and COVID-19-related death (HR 0.41).

A 2022 study also reported the safety of the BNTb262 vaccine in patients with autoimmune inflammatory rheumatic diseases. A considerably lower level of BNT162b2-induced immunogenicity was noted in patients who received treatment with glucocorticoids, rituximab, mycophenolate mofetil, and abatacept. After immunization, patients had significantly lower seropositivity rates and S1/S2 IgG levels than controls (86% vs. 100%, P <0.0001). Older age and therapy with glucocorticoids, rituximab, mycophenolate mofetil, and abatacept were identified as the risk factors for decreased immunogenicity.  The experts found that patients with autoimmune inflammatory rheumatic diseases did not exhibit any post-vaccination symptoms of COVID-19, while the control group only experienced one minor instance. They also reported that postvaccination disease activity remained steady in most patients.

Thus, patients with ARD who received the COVID-19 vaccine had a lower risk of infection, associated hospitalizations, and death. Further research is required to evaluate the long-term efficacy and safety of vaccination, the durability of the humoral vaccination response, and T-cell-mediated immunity in patients with a poor humoral response.


  1. Bieber A, Brikman S, Novack L, Abuhasira R, Fawaz A, Abu-Shakra M, et al. Fourth dose of BNT162b2 vaccine for patients with autoimmune rheumatic diseases in a nationwide setting. Rheumatology. 2023 Feb 10:kead064.
  2. Furer V, Eviatar T, Zisman D, Peleg H, Paran D, Levartovsky D, et al. Immunogenicity and safety of the BNT162b2 mRNA COVID-19 vaccine in adult patients with autoimmune inflammatory rheumatic diseases and in the general population: a multicentre study. Annals of the rheumatic diseases. 2021 Oct 1;80(10):1330-8.