Use in patients taking immunosuppressive medicines
Public Health England’s Immunisation Against Infectious Disease (The Green book) states that immunosuppressed patients, due to disease or treatment are clinically extremely vulnerable and should be vaccinated against COVID-19. According to both the Patient Group Direction for COVID-19 mRNA vaccine BNT162b2 (Pfizer/BioNTech) and the Patient Group Direction for COVID-19 Vaccine AstraZeneca, (ChAdOx1-S [recombinant]) there are no groups of potentially immunosuppressed patients that should be excluded from receiving the vaccine based on their treatment or disease alone. It is, however, noted that some immunosuppressed patients may have a suboptimal response to the vaccine and should therefore continue to avoid exposure unless they are advised otherwise by their doctor. Currently there is not an equivalent Patient Group Direction for the AstraZeneca COVID-19 Vaccine.
Patients taking immunosuppressive medicines considered a priority for vaccination
The The Green Book suggests that patients taking any of the following medicines should be part of the prioritisation process for vaccination:
- immunosuppressive chemotherapy (i.e. regimens containing any “traditional” chemotherapy)
- immunosuppressive therapy following a solid organ transplant
- immunosuppressive or immunomodulating biological therapies such as anti-TNF monoclonal antibodies, alemtuzumab, rituximab, ofatumumab
- protein kinase inhibitors such as imatinib, erlotinib, everolimus
- poly-ADP ribose polymerase (PARP) inhibitors such as niraparib, olaparib, rucaparib
- long-term immunosuppressive medicines for systemic lupus erythematosus, rheumatoid arthritis or psoriasis
- systemic corticosteroids for more than a month at a dose equivalent to prednisolone 20mg daily (any age)
- a steroid sparing medicine such as cyclophosphamide or mycophenolate
Further advice on particular patient groups
Patients being treated with immunosuppressive chemotherapy
The UK Chemotherapy Board Organisations has issued guidance on COVID-19 vaccine for patients receiving systematic anti-cancer therapy (SACT). It is recommended that all patients receiving SACT should be considered for vaccination. In terms of timing it is suggested that, if relevant, administration should be timed to coincide with when blood counts have maximally recovered but avoided on same day as chemotherapy. It is also noted that thrombocytopenia may be a minor consideration due to the need for an intramuscular injection – they state that a platelet count of >20×109/L would be preferable.
Patients being treated with rituximab
For rheumatology indications
The British Society of Rheumatology advise that:
- Where clinically possible, the COVID-19 vaccine course should be given four weeks or more before rituximab
- There may be a sub-optimal response to COVID-19 vaccines, especially for people within six months of the last dose of rituximab, or those who must have maintenance treatment due to their underlying clinical condition
- Where clinically appropriate, consideration should be given to using alternative therapies to rituximab, because of the potential that after rituximab there may be sub-optimal response to a COVID-19 vaccine. This should be on a case-by-case basis, balancing the need for rituximab and the suitability of alternative therapies for the relevant clinical situation.
For oncology indications
The UK Chemotherapy Board Organisations has issued guidance on COVID-19 vaccine for patients receiving systematic anti-cancer therapy (SACT). It is stated that patients receiving monocloncal antibodies including rituximab should be considered for vaccination. They state that there are no issues in relation to timing of vaccination when it is being used as a monotherapy provided blood counts are within acceptable range. When used in combination with cytotoxic chemotherapy administration should be coincide with when blood counts have maximally recovered but avoided on same day as chemotherapy.