COVID-19 Vaccine and Lupus (SLE): What You Should Know
People living with systemic lupus erythematosus (SLE) are more susceptible from infections like COVID-19, both due to the disease and the immunosuppressive medications used to treat it. Vaccines can reduce the risk of getting COVID infection and also of hospitalizations or serious infections from COVID. Boosters are still needed regularly as immunity from COVID vaccination and/or infection is not long lasting.
How Does Lupus Affect Life Expectancy?
With earlier diagnosis, life expectancy is showing remarkable improvements.
The improvement in life expectancy for individuals with systemic lupus erythematosus (SLE) has been remarkable. Historically, only half of those diagnosed survived for several years following diagnosis. By the late 1970s, however, survival rates had increased substantially, with 80 to 90 percent of patients living at least ten years after diagnosis.
Today, survival outcomes have improved even further, largely attributable to advances in research, earlier diagnosis, and more effective therapeutic interventions. SLE presents with a highly variable clinical course, ranging from mild to severe manifestations, and may enter periods of remission during which disease activity remains quiescent.
Is It Safe? What About Lupus Flares or New Autoimmunity?
The COVID-19 vaccine has been studied to see if it caused lupus flares or a chance of developing new autoimmune diseases.
In general, COVID-19 vaccination (SARS-CoV-2 mRNA immunization) is safe in SLE and disease flares were rare and self-limited. Mild or moderate SLE flares occurred in up to 11%, and severe flares in 1.3%, but there was no control group to determine what the SLE flare rate would be in people with SLE who were not vaccinated. A meta-analysis of various vaccines (including COVID-19) did not find evidence that vaccination increases the risk of SLE.
The benefits of vaccination outweigh any side effects in most lupus patients.
It is not fully known if people with SLE will have more autoimmune diseases due to COVID infections and/or COVID vaccinations but after the pandemic, it doesn’t appear so far that people with SLE are different than pre-COVID with respect to chances of new autoimmune diseases or SLE disease activity.
Young people with SLE are at risk of mild heart inflammation (carditis) and blood clots with COVID infection and also COVID vaccination but these are rare and usually mild events.
Why Vaccination Matters in Lupus
Infections are more common in lupus patients than in the general population, especially when they are receiving immunosuppressive treatments. People with SLE have higher serious infections with COVID compared to the general population, especially those on high-dose steroids (prednisone), rituximab and/or mycophenolate mofetil.
A study in SLE patients showed that receiving a COVID booster decreased the chance of getting COVID infection compared to those who did not get a booster.
The Canadian national immunization guidelines recommend that immunocompromised individuals should follow recommended COVID-19 vaccine schedules to maximize protection.
How Effective Is the Vaccine in Lupus?
Vaccine efficacy in SLE may be lower than in healthy people due to immunosuppressive treatments and/or lupus disease activity that can attenuate immune responses. Lupus patients produce lower antibody and cellular responses to the mRNA COVID-19 vaccines. However, some protection is still better than not receiving COVID-19 vaccinations/boosters.
Because rituximab (and obintuzimab) is given cyclically, ideally, vaccination should be 5 months after the last dose and waiting 1 month or more before re-dosing the B-cell–depleting therapy.
The timing with belimumab and anifrolumab is unknown but delaying the next dose by 2 weeks may be most optimal for mounting a better antibody response to the vaccine.
Medication Timing and Special Considerations:
Rituximab and Obintuzimab
Reduce antibodies in response to vaccinations by depleting antibody forming B cells.
It is frequently recommended to postpone additional infusions until after vaccination and to try to arrange immunization several months following a rituximab infusion.
Active SLE
Delaying vaccination until disease control is attained may occasionally increase vaccine effectiveness; however, scheduling must be weighed against the risk of infection.
Allergies / Contraindications
If you’ve had a severe allergic reaction to a component of a COVID-19 vaccine, discuss alternatives with your physician.
Women who are pregnant can receive the COVID vaccination to render protection for them and their baby.
Other Immunosuppressants / Biologics / Corticosteroids
According to guidelines from the American College of Rheumatology (ACR), patients with stable immunosuppression should typically not be denied non-live immunizations, including the COVID-19 vaccine; however, they may not be as effective compared to the general population.
Vaccinating when prednisone is below 10 mg/day is better than higher-dose glucocorticoids.
Holding immunosuppressives for up to 2 weeks after a vaccination may provide the most ideal response if the SLE is inactive or in low disease activity, but restarting the medications earlier may be needed if a flare is imminent.
What To Expect and When To Get the Vaccine
Eligible lupus patients should continue to receive regular COVID-19 boosters.
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Boosters are strongly encouraged, especially in immunocompromised individuals.
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Common side effects are mild and similar to the general population: sore arm, fatigue, low-grade fever.
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Serious side effects are rare.
In Canada, currently COVID boosters are recommended prior to peak infections, so the same time as the flu shot. Whether the booster should be given more than once a year is not totally certain but in some patients with a weakened immune system, COVID boosters may be given twice a year.
Regarding the best time to have your immunization in relation to your lupus treatments and disease activity, always consult your health care provider.
Authors: Daniel Tingey and Doctor Janet Pope
Note: Please consult your healthcare provider or local health authorities for up-to-date vaccine recommendations.