Most frequently asked questions in rheumatology clinics answered

Rheumatologists in Hong Kong joined hands to develop a set of consensus statements on COVID-19 vaccination for local adult patients with autoimmune rheumatic diseases. These timely statements would serve to be a guide for rheumatologists, other specialists, family physicians, specialty nurses, and the public regarding COVID-19 vaccination for patients with rheumatic diseases.

Vaccination against SAR-CoV-2 is a new campaign and a high immunization rate is believed to be the key to end the pandemic. Currently, there are two COVID-19 vaccines available in Hong Kong—the inactivated virus vaccine CoronaVac (Sinovac) and the mRNA-based vaccine Comirnaty (BioNTech/Fosun). However, due to the paucity of experience in patients with autoimmune rheumatic diseases, there are concerns from patients regarding the efficacy and safety of the new COVID-19 vaccines. This underscores the importance of input from rheumatologists in providing appropriate advice to patients with autoimmune rheumatic diseases and other health-care providers on the COVID-19 vaccines.

The Hong Kong Society of Rheumatology (HKSR) took the lead to develop a set of consensus statements for the use of COVID-19 vaccines in local adult patients with autoimmune rheumatic diseases. Twenty-seven core members of the HKSR, including council members and rheumatologist-in-charge of most hospitals, met by teleconference on March 19, 2021, to discuss clinical questions related to COVID-19 vaccination in adult patients with autoimmune rheumatic diseases. Important clinical questions were summarized and statements were drafted. A systemic literature search was subsequently conducted to identify and grade the relevant evidence and the strength of recommendations for each statement.

A total of eight statements were finalized. Full members of the HKSR were invited to show their agreement to the statements in an on-line survey. Consensus of all the eight statements was reached after two rounds of voting. The eight statements with their grade of evidence and strength of recommendations are:

Statement 1: "There is limited evidence to suggest that adult patients with autoimmune rheumatic diseases have increased risk of COVID-19 infection."Grade of Evidence: CStrength of recommendation: B

Statement 2: "Adults patients with autoimmune rheumatic diseases may develop more severe COVID-19 infection than the general population."Grade of Evidence: CStrength of recommendation: A

Statement 3: "Vaccination against COVID-19 is recommended for patients with autoimmune rheumatic diseases that are under reasonable control. Local guidelines and precautions of the respective vaccines should be followed."Grade of Evidence: DStrength of recommendation: A

Statement 4: "The immunogenicity of various COVID-19 vaccines in patients with autoimmune rheumatic diseases is currently uncertain. In view of the concomitant immunomodulating/ immunosuppressive medications, the efficacy of these vaccines might be compromised."Grade of Evidence: CStrength of recommendation: B

Statement 5: "There is no evidence of increased risk of disease flares or adverse events in autoimmune rheumatic diseases, in the absence of other comorbidities, after COVID-19 vaccination."Grade of Evidence: CStrength of recommendation: A

Statement 6: "There is currently no evidence that adjusting the dosage schedule of immunosuppressive drugs would enhance the efficacy of the COVID-19 vaccines."Grade of Evidence: DStrength of recommendation: B

Statement 7: "In patients using heavy immunosuppressive or multiple treatment modalities, particularly those with long half-lives, a discussion with attending rheumatologists is suggested for the need to adjust dosage schedule on an individual basis."Grade of Evidence: DStrength of recommendation: B.

Statement 8: "In patients receiving rituximab, COVID-19 vaccine is best administered shortly before the next due dose. When the underlying autoimmune rheumatic diseases are stable, postponement of rituximab infusion for 4 weeks might be considered."Grade of Evidence: DStrength of recommendation: B

"This set of consensus recommendations was developed by more than 60% of the practicing rheumatologists in our locality. It took into consideration the limited existing evidence and local perspectives such as the availability of specific vaccines as well as the outbreak situation in Hong Kong. Our recommendations also emphasize patient-centered discussion and individualized decision," says Dr. Chi Chiu Mok, the lead of the project, of Tuen Mun Hospital.

"Specific trials on various aspects of COVID-19 vaccines in patients with rheumatic diseases are expected to flourish in the coming months. The information in the current recommendations will likely need to be updated upon the emergence of new data." adds Dr. Ronald Yip, the President of the HKSR.