American College of Rheumatology Revises COVID-19 Vaccine Clinical Guidance, Supports 4th Dose

The American College of Rheumatology (ACR) has published guidance regarding COVID-19 vaccination for immunocompromised patients, with emphasis placed on supplemental and booster doses, recommendations for the timing of those injections concerning immunomodulatory medication, and pre- and post-exposure prophylaxis with monoclonal antibody treatment.

The ACR curated the North American Task Force panel, consisting of 9 rheumatologists, 2 infectious disease specialists, and 2 public health experts. The panelists created a list of clinical questions and that were then rated with a numerical score on level of agreement. Only questions with “moderate” (M) or “high” (H) agreement and importance were included in the draft.

“It remains important for rheumatology providers to assess the vaccination status of all patients with rheumatic diseases,” Jeffrey Curtis, MD, Chair of the ACR COVID-19 Vaccine Guidance Task Force, stated. “Initially, it might have been acceptable to just ask a patient if they have been vaccinated. There is now more nuance with supplemental and booster dose recommendations that should prompt us to ask patients not only whether they have been vaccinated, but with what, how many times, and how recently.”

Changes in the 5th version of the guidelines are listed below:

Top Insights:

• Patients with autoimmune inflammatory rheumatic disease (AIIRD) who have completed the primary COVID vaccine series and have an inadequate vaccine response should receive the booster dose (3rd dose) as recommended by the Centers for Disease Control and Prevention (CDC) for immunocompromised people.
• Patients with rheumatic and musculoskeletal diseases (RMD) who have completed a primary COVID vaccine series, and any supplemental doses, should receive booster dose(s) as recommended by the CDC for immunocompromised individuals.
• It is strongly recommended that primary vaccination, supplemental dosing, and booster doses should be given regardless of COVID-19 infection.
• For high-risk patients with AIIRD, pre-exposure prophylaxis monoclonal antibody treatment is recommended if available.
• Patients with AIIRD patients who are at higher risk for poor outcomes related to COVID should receive monoclonal antibody therapy, either as prevention or as treatment for newly symptomatic patients.
• No modifications to immunomodulatory hydroxychloroquine or IVIg therapy or vaccination timing.