COVID-19 advice for people with inflammatory arthritis and related autoimmune diseases

Arthritis New Zealand-New Zealand Rheumatology Association position statement – COVID-19 advice for people with inflammatory arthritis and related autoimmune diseases

September 2022

General advice during the COVID-19 pandemic

People with rheumatic disease should get vaccinated against COVID-19, including any recommended booster vaccinations, and observe all public health measures (such as mask wearing and hand washing) as recommended by the New Zealand Ministry of Health.

Studies published to date have shown that use of most oral disease-modifying anti-rheumatic drugs (DMARDs) and most biological therapies for arthritis do not increase the risk of infection, hospitalization or mortality caused by SARS-CoV-2 (the novel coronavirus). Studies have shown that people with poorly controlled inflammatory disease are at increased risk of severe illness due to COVID-19. It is therefore recommended that people with inflammatory disease continue to take their medications during the pandemic, and try to minimize use of corticosteroids such as prednisone. Use of rituximab, mycophenolate, sulfasalazine, or prednisone greater than 10 mg per day have been associated with an increased risk of severe illness due to COVID-19. It is very important to have well controlled inflammatory disease, so do not stop these medicines and discuss this with your rheumatologist.

COVID-19 vaccination advice

COVID-19 vaccination can be given safely to people on DMARDs, and is strongly recommended for all eligible people with rheumatic disease.

People on rituximab, cyclophosphamide, and most oral DMARDs (including methotrexate, leflunomide, azathioprine, mycophenolate, tacrolimus, and cyclosporin) are eligible for a third primary dose of the Comirnaty (Pfizer) vaccine eight weeks after the second dose, in accordance with the New Zealand Ministry of Health guidance. People on long-term prednisone ≥10mg daily are also eligible for a third primary dose. Further booster vaccine doses should also be given after the third primary vaccine, as recommended by the Ministry of Health.

After each vaccine dose, oral DMARDs (but not prednisone or hydroxychloroquine) should be withheld for 1-2 weeks, if disease activity and severity allow. This recommendation is to increase the effectiveness of the vaccine rather than due to concerns about safety.

Evusheld (tixagevimab with cilgavimab) for pre-infection prophylaxis

Evusheld is now funded for people who are severely immunocompromised to protect them from getting COVID-19 or from becoming very sick if they get COVID-19. People with rheumatic disease who have received rituximab in the previous 12 months or high dose cyclophosphamide within previous 6 months are eligible for Evusheld, and can discuss this with their rheumatology team. Evusheld is given by injection every 6 months.

Advice for people who develop COVID-19 infection

The New Zealand Ministry of Health provides advice for all New Zealanders about how to look after yourself while you have COVID-19.
Oral DMARDs and biologics (but not prednisone) should be withheld until recovery from COVID-19 infection, if rheumatic disease activity and severity allows.
Anti-viral therapies such as Paxlovid are now funded for those people who were eligible for the third primary dose of the COVID-19 vaccine who have COVID-19 infection. Most people who are on DMARD therapy are eligible for this treatment, which should be initiated as early as possible and within five days of symptom onset.

There are important drug-drug interactions between Paxlovid and medications used in rheumatology care, including cyclosporin, tacrolimus, colchicine, upadacitinib, sildenafil, and prednisone.

For some people on high doses of immunosuppression, particularly rituximab, prolonged COVID-19 infection may occur. The care of these people should be discussed with a specialist infectious diseases team, as longer periods of isolation and additional testing may be needed in this situation.