The COVID Vaccines and Autoimmune Disease

As the COVID vaccine rolls out, people with arthritis and other autoimmune diseases are wondering what this means for them. Is the COVID vaccine safe if you’re taking immunosuppressants, like methotrexate, Humira, Enbrel, and other biologics? Does it work?

We don’t have all the answers to these questions, unfortunately. The vaccines are too new, and they haven’t been fully tested on immunocompromised people. That doesn’t mean we can’t find some guidance, though. So, what do we know so far about the COVID vaccine for people with autoimmune diseases?

(I am not a doctor, and more importantly, I and others on the internet are not your doctor. Each person is unique, so talk to your doctor for details specific to your own health and treatment.)

Immunosuppression in autoimmune disease

First, it’s important to know that people with autoimmune diseases aren’t naturally immunosuppressed. That said, the autoimmune disease may make it harder for the body to fight off infection. This is why, at the beginning of the pandemic, people were urged to stay on their medication until we learned more. Going off autoimmune medication means your body can go into a flare in response, which leaves you ill-equipped to fight COVID. It’s like your immune cells are firefighters too exhausted from putting out fake fires to fight a real fire.

But then, of course, the medications we take to control autoimmune diseases suppress our immune systems. Common immunosuppressant medications include prednisone; DMARDs like methotrexate and Plaquenil (hydroxychloroquine); and biologics like Humira, Enbrel, Cosentyx, and Stelara.

Vaccines and immunosuppression

Vaccines work to train your immune system to recognize a virus or bacteria as an intruder. They work because, when your body recognizes the intruder immediately, it can start fighting it immediately. If it’s the first time your immune system has seen a pathogen, it takes awhile for it to realize something is wrong and build up an attack, and during that time you feel sick as the virus or bacteria attacks you.

There are different types of vaccines. Some are made from a weakened form of a live virus. These are the vaccines that you cannot take if you’re taking a biologic or immunosuppressant. Examples of live virus vaccines include chickenpox, MMR, and flu nasal vaccines. (The flu shot you get in your arm is not a live vaccine.)

Most common vaccines do not contain whole, live viruses or bacteria. They contain an inactivated virus or bacteria or only part of the virus or bacteria. This allows the immune system to recognize and remember the pathogen, but there’s no way for it to make you sick. Examples of these vaccines include the flu shot, meningitis vaccine, and pneumococcal vaccine.

Vaccines have been known to work less well in people who are immunosuppressed. For some vaccines, it doesn’t really matter much (like the flu shot). For others, there’s a decreased response, which could possibly make the vaccine less effective. Luckily, there’s no evidence that simply having an autoimmune disease makes vaccines less effective.

There also isn’t evidence that getting a vaccine makes an autoimmune disease worse in the long run. Some people report extra joint pain and symptoms in the week following the vaccine, but this is short-term and may just be due to the immune activation that’s necessary to successfully build immunity. It also doesn’t mean you’re sick with whatever you were vaccinated for, since most vaccines don’t contain live virus. In these cases, it’s your own immune system making you feel sick, unfortunately.

The COVID vaccines

The Moderna and Pfizer vaccines aren’t live vaccines, so they’re considered safe for people on biologics. The COVID vaccines are a new type of vaccine called an RNA vaccine.

RNA, if you remember from science class, is like the messenger for DNA. It carries instructions to different parts of the cell, telling them how to make important proteins. The COVID RNA vaccine contains instructions for cells to make the COVID “spike protein,” which is harmless and found on the surface of a COVID particle. The immune cells use those instructions to make that protein (which is a one-time thing—the instructions are broken down after use).

Once the immune cells make the COVID spike, other cells recognize it as something that shouldn’t be there. In response, they make antibodies, so that they remember it if they ever encounter a real COVID virus. Importantly, the RNA vaccine does not contain any whole or partial COVID virus, and the RNA only codes for a harmless protein, like a COVID ID tag. It’s like putting up wanted posters so that we can recognize a dangerous criminal without seeing them up close and in-person.

We don’t know yet whether immunosuppressants and biologics effect the immune response for the COVID vaccines. They haven’t been studied in people with autoimmune diseases taking immunosuppressants because they received Emergency Use Authorizations. As a result, the vaccines did not complete the full regulatory pathway. This doesn’t mean they’re not safe. They were tested for safety, and other vaccines like them have been studied for years. However, the COVID vaccines were not studied in patients with serious pre-existing conditions (like autoimmune arthritis or inflammatory bowel disease) before being made available to the general population.

Is it better to stop biologics before the vaccine, so that we can form a better immune response? Doctors haven’t decided yet, and there may be no right answer. However, some doctors say it may be worth pausing your immunosuppressant. This has been shown effective for methotrexate users to build better immunity from vaccines.

If you’re considering pausing a medication, always talk to your doctor to make sure it’s appropriate for you. Pausing or stretching immunosuppressant doses may not be possible for some people who would flare badly by delaying their dose by even a week. (I know from experience this would be the case for me.) Pausing a biologic also makes it more likely you’ll develop antibodies to it. If you can’t stop it, doctors recommend getting the vaccine as far as possible from your last biologic or immunosuppressant dose. In the end, getting the vaccine while on immunosuppressants is better than not getting the vaccine at all.

Unfortunately, we’re still waiting for the American College of Rheumatology to release an official position. Still, the consensus among doctors shows in statements from the Arthritis Foundation, the Spondylitis Association of America, and the annual meeting of IBD physicians. In summary, your doctor is the best one to talk to about this, but just having an autoimmune disease or taking a biologic does not disqualify you from getting the COVID vaccine.

Here’s to hoping the vaccine gets out there fast! Stay safe, everyone.

-Bri

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