COVID-19 Vaccination and Psoriatic Arthritis

John Tesser, MD: I want to dive into the waters of COVID-19 figuratively, clearly not absolutely. Let’s start discussing COVID-19 vaccinations in patients with rheumatic and musculoskeletal diseases. Let’s first touch on the importance of it and get into if it’s recommended. What are the potential problems? What are the difficulties and challenges we have in recommending them to our patients? Jen, how do you feel about the value of vaccination? What’s your understanding of how our field, through guidelines that have been coming down the pike, is advising us to recommend [the vaccine] to our patients?

Jennifer Simpson, DNP: Vaccinations are very important for our patient population. Their immune systems aren’t functioning the way they should be, so they’re at high risk for contracting these infections and having worse complications from them than someone without this type of disease. Vaccinations are definitely very important and should be reiterated and encouraged to our patients, and they should talk with their primary care providers about this as well. It’s important to note to our patients that they may get a vaccine and it may not be as effective for them as the next person, which is why getting their [COVID] boosters and being on top of the timing with that are so important.

Generally speaking, we’re still understanding, and getting more information about how we need to make recommendations to our patients as far as how to take medicine, hold their medication, and how that’s going to affect the vaccine efficacy. On our team we’ve been having patients hold their medications for a week after receiving their vaccine. What I’ll often tell a patient who’s on a once-a-week type of schedule, say with etanercept or with their methotrexate, is to get their flu shot and the COVID-19 vaccine on that date they’re due for their injection or pills. That way, they’re getting a week before or week after with their coverage, and hopefully that will be enough for them to mount some type of immune response.

That being said, in the general population, people think if they don’t feel well after getting a vaccine, it caused them to be sick. [We need to] manage expectations with our patients, explaining to them you kind of want to feel unwell after getting a vaccine. It’s telling your body you’re mounting a response to what you’ve received. You’re building those antibodies, and that’s what your immune system is doing when you’re not feeling great after getting a vaccine. That’s what you want. It’s working. A lot of people in the general population think that’s a bad thing and that they’re getting sick and you’re not, but it’s working.

I definitely think we need to encourage our patients and not make them feel unwelcome because you have certain patients for whom COVID-19 has been very polarizing, unfortunately, from a political standpoint. [We need to] take note of that for patients and not trying to make them feel uncomfortable in any sense. I always tell my patient, “It’s just my job to give you the expert opinion on what’s going on and give you our viewpoint, but at the end of the day, it’s your decision. It’s whatever you feel comfortable with because you’re the one who has to live with the good, the bad, and the ugly of whatever happens. It’s my job to tell you how it is, and from there you get to decide.” Vaccines do go into that, especially with COVID-19, but we have to have a strong stance and really explain to patients why it’s so important for them to get it.

John Tesser, MD: You covered some very important points. Several of them got us through the guidelines that we have working for us. I totally agree with you. Your comments are in concert with what the ACR [American College of Rheumatology] guidance has been, and it has been changing over time. There’s a notion of things changing over time: we don’t need masks, we need masks; you need to get your vaccine, maybe you don’t need it, maybe it won’t help you, etc. But that’s how science works; everything changes. As you learn more, you change. The ACR definitely recommends to all our patients that they be vaccinated.

I agree: it needs to be a shared decision-making process. There are all kinds of reasons why people are hesitant about the vaccine, from the political, to the scared, to not wanting their disease to flare, to not believing it works, or thinking they’re going to grow 3 heads 10 years from now. But your approach is not to belittle patients, to ask them what their hesitancy is about it, and then to give them confidence. Some patients are confused because of all the misinformation and disinformation out there.

If they hear from their clinician that they recommend getting it, and now they’re hearing from their doctor, and you’re a doctor too. We know that sways a lot of people in terms of their understanding. I take the stance and tell them I’m a clinical immunologist. I do understand a fair amount about the immune system. We manipulate the immune system with our medicines. Vaccines are a brilliant mechanism to manipulate the system to teach it what COVID-19, the SARS-CoV-2 virus, looks like so it can recognize it. That it is a manner by which they can be protected, and that the American College of Rheumatology also advises it. You touched on holding their immunotherapies. We don’t know the right answer to this. We’ve been advised by the ACR with best guesses about what to do. In fact, we’re doing a study, called the COVER study, identifying patients who are ready to get boosters who are on these biologics and small-targeted molecules, to see if they hold their medicines and what their response will be after they get their booster shot. We’re trying to figure this out. We don’t know the answers. We’re just flying by the seat of our pants as far as that goes.

This transcript has been edited for clarity.