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Vaccine Guidance: Additional dose after a primary mRNA vaccine series in immunocompromised patients

Below includes a summary of recommendations from the CDC to address the administration of an additional dose after a primary mRNA vaccine series in immunocompromised patients who had previously received the Pfizer-BioNTech or Moderna vaccine. Currently, the CDC does not recommend an additional dose for those who are immunocompromised and have received the Johnson & Johnson COVID-19 vaccine. This information is current as of 8/17/21.

Per the CDC Advisory Committee on Immunization Practices (ACIP), patients who are actively being treated with: High dose corticosteroid (≥20mg prednisone), Alkylating agents (cyclophosphamide), Antimetabolites (azathioprine), TNF blockers (infliximab, adalimumab, etanercept, golimumab, certolizumab pegol) and other biologics that are immunosuppressive or immunomodulatory, qualify for an additional dose of the Covid-19 vaccine. Patients getting the Pfizer vaccine need to be at least 12 years of age. Those getting the Moderna vaccine need to be at least 18 years of age.

The third dose needs to be administered at least 28 days (about 4 weeks) after completion of the primary mRNA vaccine series. Ideally, the third vaccine dose should be the same product (either Pfizer or Moderna) as the first two doses. Patients with rheumatic disease are still advised to continue preventative measures to reduce exposure to the virus.

**Medication hold timing modeled after the American College of Rheumatology (ACR) and data extrapolated from previous studies**

Medication	Recommendation
Corticosteroid: Prednisone and Equivalent < 20 mg/day	No modification to either immunomodulatory therapy or vaccination timing
Corticosteroid: Prednisone and Equivalent > 20 mg/day for at least 14 days	Taper steroid down, if possible, to <10 mg/day before administering the vaccine
Hydroxychloroquine	No modification to either immunomodulatory therapy or vaccination timing
Apremilast
Intravenous immune globulin (IVIG)
Sulfasalazine	No modification to either immunomodulatory therapy or vaccination timing
Leflunomide
Azathioprine
Cyclophosphamide (oral)
TNFi
IL-6R, IL-1R, IL-17, IL-12/23, IL-23
Belimumab
Calcineurin inhibitors (oral)
Mycophenolate	Hold mycophenolate for 1 week following 3rd vaccine dose
Methotrexate	High risk of disease flares: vaccine available for administration at least 3-4 days (at most 7 days) following methotrexate dose and hold 1 methotrexate dose following an additional vaccination   Low risk of disease flares:  vaccine available for administration at least 3-4 days (at most 7 days) following methotrexate dose and hold 2 methotrexate doses following an additional vaccination
JAK inhibitors	Hold JAK inhibitors for 1 week after vaccination
Abatacept (SQ)	Hold abatacept for 1 week before vaccination and 1 week after vaccination
Abatacept (IV)	Time the vaccine administration to four weeks after abatacept infusion and postpone the subsequent abatacept infusion by 1 week
Cyclophosphamide (IV)	Time the administration of cyclophosphamide to occur at least 1 week after vaccine administration
Acetaminophen, NSAIDs	With stable disease, hold for 24 hours prior to vaccination. There is no restriction on use for symptomatic patients post vaccination
Rituximab	Schedule an additional vaccine 4 weeks prior to next rituximab cycle; following an additional vaccination continue cycle as scheduled

 

For more information: Please visit the CDC website at “COVID-19 Vaccines for Moderately to Severely Immunocompromised People | CDC” or scan the QR code:

 

 

 

References:

1. COVID-19 Vaccines for Moderately to Severely Immunocompromised People [Internet]. Aug 16, 2021 [accessed Aug 17, 2021]. Available from: COVID-19 Vaccines for Moderately to Severely Immunocompromised People | CDC
2. Curtis, J.R., Johnson, S.R., Anthony, D.D., Arasaratnam, R.J., Baden, L.R., Bass, A.R., Calabrese, C., Gravallese, E.M., Harpaz, R., Sadun, R., Turner, A., Williams, E.A. and Mikuls, T.R. (2021), American College of Rheumatology Guidance for COVID-19 Vaccination in Patients with Rheumatic and Musculoskeletal Diseases: Version 3. Arthritis Rheumatol, 73: 1093-1107.
3. Arnold J, Winthrop K, Emery P. COVID-19 vaccination and antirheumatic therapy. Rheumatology (Oxford). 2021 Aug 2;60(8):3496-3502.