Holding DMARDs Not Associated With Greater RA Activity After Additional Dose of COVID-19 Vaccine

Doctor with blue gloves gives vaccine shot to shoulder of a woman

The COVID-19 vaccination guidelines of the American College of Rheumatology (latest version dated February 2022) suggest that patients with rheumatic and musculoskeletal diseases should hold (interrupt their use of) certain immunomodulatory or immunosuppressive medications for one to two weeks after COVID-19 vaccination, assuming disease activity allows. The goal is to improve the immunogenicity of the vaccine.

Among patients with rheumatoid arthritis (RA), researchers at Brigham and Women’s Hospital found that patient-reported disease activity stayed stable around the time of COVID-19 vaccination when disease-modifying anti-rheumatic drugs (DMARDs) were held.

Sara K. Tedeschi, MD, MPH, co-director, Fast Track Clinic for Giant Cell Arteritis, and Daniel H. Solomon, MD, MPH, rheumatologist, both in the Division of Rheumatology, Inflammation and Immunity, and colleagues report the details in a research letter published in the Annals of the Rheumatic Diseases.


The prospective observational study involved 71 patients with RA who had previously received two doses of the Pfizer vaccine (51%), two doses of the Moderna vaccine (42%), or one dose of the Johnson & Johnson vaccine (7%). The participants were enrolled between July and November 2021, before receiving an additional dose of COVID-19 vaccine.

Each week from enrollment through week 4 after the additional dose, participants completed the RA Disease Activity Index–5 (RADAI-5) online. Two days after receiving the additional dose, they completed an online survey about vaccine reactogenicity and whether they were holding or continuing DMARDs.

Overall Results

The key results were:

  • 35 participants (49%) held at least one DMARD
  • The mean RADAI-5 score in the entire study population was 3.20 pre- vs. 3.25 post-additional dose (difference of 1.6%, p=0.51)
  • Mean pre- vs. post-additional dose RADAI-5 scores did not differ significantly either among participants who held DMARDs or in participants who continued all DMARDs
  • The mean pre- to post-additional dose change in RADAI-5 did not differ significantly based on whether participants held vs. continued DMARDs (P for interaction, 0.16)

Immune Cell Populations

The researchers obtained pre- and post-additional dose blood samples for 27 participants with seropositive RA. They measured percentages of four lymphocyte populations associated with immune activation in RA: T peripheral helper cells, T follicular helper cells, age-associated B cells, and plasmablasts.

Frequencies of these lymphocyte subsets did not change significantly pre- vs. post-additional dose either in subjects who held at least one DMARD (n=16) or subjects who continued all DMARDs (n=11).


These results suggest that RA disease activity is stable around the time of an additional dose of COVID-19 vaccine (e.g., third dose of mRNA vaccine) even if DMARDs are held. Although the number of participants was low, the study was powered to detect a pre- versus post-dose difference in RA activity of 15%.

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