EULAR recommendations for the management and vaccination of people with rheumatic and musculoskeletal diseases in the context of SARS-CoV-2: the November 2021 update

Abstract

The first EULAR provisional recommendations on the management of rheumatic and musculoskeletal diseases (RMDs) in the context of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), largely based on expert opinion, were published in June 2020. Since then, an unprecedented number of clinical studies have accrued in the literature. Several SARS-CoV-2 vaccines have been approved for population-wide vaccination programmes in EULAR-affiliated countries. Studies regarding vaccination of patients with (inflammatory) RMDs have released their first results or are underway.EULAR found it opportune to carefully review to what extent the initially consensus expert recommendations stood the test of time, by challenging them with the recently accumulated body of scientific evidence, and by incorporating evidence-based advice on SARS-CoV-2 vaccination. EULAR started a formal (first) update in January 2021, performed a systematic literature review according to EULAR’s standard operating procedures and completed a set of updated overarching principles and recommendations in July 2021. Two points to consider were added in November 2021, because of recent developments pertaining to additional vaccination doses.

Shielding reduced incidence of COVID-19 in patients with inflammatory arthritis but vulnerability is associated with increased mortality

“…The EULAR produced guidelines at the beginning of the pandemic and updated these recently with more evidence-based recommendations. Findings were similar to UK and US guidelines; however, EULAR suggests continuing with the treatment regimen even in the case of suspected or confirmed COVID-19, with the exception of rituximab [16,17].…”

“…When shielding practices were investigated in a cross-sectional study of nearly 500 RA individuals from Boston, USA, the use of DMARDs and glucocorticoids were both associated with increased adherence to shielding practices in the United States [ 18 ]. However, non-compliance with DMARDs has been shown to slightly increase during the pandemic in a study conducted in Switzerland [ 17 ].…”

High T-cell response rate after COVID-19 vaccination in belimumab and rituximab recipients

“…In these patients, we suggest that mycophenolate be withdrawn for one or two weeks after the vaccination if the disease is stable, according to published data [ 5 ]. No data are available regarding the effect of withdrawing calcineurin inhibitors [ 27 ], even though this would be advisable based on the immunogenicity observed in solid organ transplant recipients [ 28 ].…”

Effect of a 2-week interruption in methotrexate treatment versus continued treatment on COVID-19 booster vaccine immunity in adults with inflammatory conditions (VROOM study): a randomised, open label, superiority trial

“…Consequently, there is conflicting advice on whether to continue or interrupt methotrexate treatment after COVID-19 vaccination. 11 , 12 , 13 Understanding the effectiveness and safety of this simple intervention would provide valuable and timely guidance to achieve enhanced, durable immunity following COVID-19 vaccination in this clinically susceptible population, informing clinical practice and public health policy when additional vaccinations are being considered globally. This understanding is especially important given the high impact that the COVID-19 pandemic has had on the physical, social, and psychological wellbeing of this patient group, the current high transmission rates of SARS-CoV-2 worldwide, and the reduced vaccine efficacy against the omicron (BA.1.1.529) and BA.2 variants due to attenuated cross-reactive neutralising antibody potency.…”