key: cord-0749296-5a3v6pmg
authors: Mortezavi, Mahta; Menon, Sujatha; Lee, Kristen; Rivas, Jose
title: Commentary on the American College of Rheumatology “COVID‐19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases”: use of tofacitinib in the context of COVID‐19 vaccination
date: 2021-05-27
journal: Arthritis Rheumatol
DOI: 10.1002/art.41806
sha: ab627fdf7b412a592816d2c11e721c120f414697
doc_id: 749296
cord_uid: 5a3v6pmg

We read with great interest the ACR’s COVID‐19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases (1). We commend the Task Force’s emphasis on the importance of immunization in this population and for providing guidance to the rheumatology community. Regarding their recommendation to hold Janus kinase (JAK) inhibitors for 1 week after each COVID‐19 vaccine dose (1), we propose the following available tofacitinib data for consideration in this context.

We read with great interest the ACR's COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases (1) . We commend the Task Force's emphasis on the importance of immunization in this population and for providing guidance to the rheumatology community. Regarding their recommendation to hold Janus kinase (JAK) inhibitors for 1 week after each COVID-19 vaccine dose (1), we propose the following available tofacitinib data for consideration in this context.

Tofacitinib is a reversible JAK inhibitor characterized by rapid absorption and elimination, and a short half-life (2) . The impact of tofacitinib on lymphocyte subsets consists of small and variable changes in T cell counts, increases in B cell counts, and decreases in natural killer (NK) cell counts. After drug discontinuation, B and NK cell counts can take from 2 to 6 weeks to return to baseline levels (2) , which suggest that the impact of a 1-week hold of tofacitinib on immune cell counts would likely be small.

Studies have also shown that T-cell dependent (TCD) and T-cell independent (TCI) vaccine responses are unaffected by tofacitinib (3, 4) . In one study, rheumatoid arthritis patients on tofacitinib 10 mg BID (+/-methotrexate) were randomized to continue or to stop tofacitinib, 1 week prior and 1 week following immunization with the 23-valent pneumococcal polysaccharide vaccine (PPSV-23) or the trivalent influenza vaccine (3). Antibody titers measured 35 days post-immunization were satisfactory in both continue and hold groups for PPSV-23 (75.0% and 84.6%, respectively; TCI) and influenza vaccine (66.3% and 63.7%, respectively; TCD) (3). In another study, psoriasis patients on tofacitinib 10 mg BID demonstrated a robust vaccine response to TCD tetanus toxoid (88%) and 13valent pneumococcal (80%) vaccines (4).

As with any clinical decision, patient risk:benefit analysis includes the potential for disease flares. In the aforementioned study, tofacitinib treatment interruption showed a steady increase in disease activity measures compared with continuous treatment (Figure 1 ) (5) . Therefore, in addition to the ACR guidelines, we encourage clinicians to consider the above data during shared decision-Accepted Article

Vaccine Clinical Guidance Task Force. COVID-19 vaccine clinical guidance summary for patients with rheumatic and musculoskeletal diseases

The mechanism of action of tofacitinib -an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis

The effect of tofacitinib on pneumococcal and influenza vaccine responses in rheumatoid arthritis

T cellmediated immune response to pneumococcal conjugate vaccine (PCV-13) and tetanus toxoid vaccine in patients with moderate-to-severe psoriasis during tofacitinib treatment

Re-establishment of efficacy

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