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Considerations for Pharmacologic Management of Rheumatoid Arthritis in the COVID-19 Era: a Narrative Review

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Abstract

Purpose of Review

To review the impact of disease-modifying antirheumatic drugs (DMARDs) on COVID-19 severity and vaccine immunogenicity and to discuss COVID-19 outcomes in patients with rheumatoid arthritis (RA).

Recent Findings

Rituximab is associated with severe COVID-19 and impaired vaccine immunogenicity via its B cell-depleting mechanism. JAK inhibitors and glucocorticoids have been modestly associated with severe COVID-19 and impaired vaccine immunogenicity. TNF inhibitors may have a protective effect against severe COVID-19 and do not appear to affect vaccine immunogenicity. Clinical trials have shown improved seroconversion and antibody titers when methotrexate is held around vaccine doses, but this may yield increased risk of RA flare. Patients with RA are also impacted by DMARD disruption, RA flares, and post-acute sequelae of COVID-19 after COVID-19 infection.

Summary

Given the risks of COVID-19, rituximab should be used with caution in RA. Holding methotrexate doses around COVID-19 vaccination improves immunogenicity but may increase RA flare risk.

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Funding

ZSW is funded by the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers R01 AR080659, K23 AR073334, and R03 AR078938), and the Rheumatology Research Foundation (K Supplement). JAS is funded by the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers R01 AR080659, R01 AR077607, P30 AR070253, and P30 AR072577), the R Bruce and Joan M Mickey Research Scholar Fund, and the Llura Gund Award funded by the Gordon and Llura Gund Foundation. The funders had no role in the decision to publish or in the preparation of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard University, its affiliated academic health care centers, or the National Institutes of Health.

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Authors and Affiliations

  1. Tufts University School of Medicine, Boston, MA, USA

    Rathnam Venkat

  2. Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA

    Zachary S. Wallace

  3. Department of Medicine, Massachusetts General Hospital, Clinical Epidemiology Program, Mongan Institute, Boston, MA, USA

    Zachary S. Wallace

  4. Harvard Medical School, Boston, MA, USA

    Zachary S. Wallace & Jeffrey A. Sparks

  5. Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, 60 Fenwood Road, #6016U, Boston, MA, 02115, USA

    Jeffrey A. Sparks

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  1. Rathnam Venkat
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Correspondence to Jeffrey A. Sparks.

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Conflict of Interest

RV reports no conflicts of interest. ZSW reports research support from Bristol Myers Squibb and Principia Sanofi; consulting fees from Zenas Biopharma, Visterra Otsuka, Horizon, Sanofi, Shionogi, Viela Bio, and MedPace; and participation on advisory boards for Sanofi and Horizon. JAS reports research support from Bristol Myers Squibb; and consulting fees from AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, Pfizer, and ReCor.

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Venkat, R., Wallace, Z.S. & Sparks, J.A. Considerations for Pharmacologic Management of Rheumatoid Arthritis in the COVID-19 Era: a Narrative Review. Curr Rheumatol Rep 25, 236–245 (2023). https://doi.org/10.1007/s11926-023-01111-y

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