A randomized trial has settled a lingering pandemic-era question: should patients with inflammatory arthritis pause their targeted immunosuppressant drugs before a COVID-19 vaccine? The answer, according to results published in JAMA Internal Medicine, is no. Among 840 patients assigned to either a two-week hold of their biologic or targeted DMARD or to continue their usual schedule, antibody rises against the SARS-CoV-2 spike protein were nearly identical six weeks after vaccination (geometric mean fold rise ratio 0.96, 95% CI 0.36-2.56).
However, the drug holiday came with a clear cost. Patients who paused their medication had more than double the odds of a new arthritis flare (OR 2.27, 95% CI 1.41-3.65). Clinically meaningful worsening on the OMERACT flare questionnaire occurred in 21.1% of the hold group versus 9.1% of those who continued their drugs, with most flares appearing in the first two weeks after vaccination and resolving by six weeks.
The COVER trial enrolled 602 rheumatoid arthritis patients, 198 with psoriatic arthritis, and 40 with spondyloarthritis, covering a range of therapies including TNF inhibitors, JAK inhibitors, IL-17 inhibitors, and abatacept. The researchers noted that some drug classes, such as methotrexate, JAK inhibitors, and abatacept, were associated with muted immune responses regardless of holding, suggesting that vaccination status should ideally be optimized before starting biologic therapy. Limitations included a 31% loss to follow-up and the possibility that a two-week hold was too short for a full washout of some drugs, but the authors concluded that routine temporary interruption is not supported for COVID-19 vaccine optimization.