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What Axial Spondyloarthritis Patients Need to Know About the COVID-19 Vaccine-logo
Credit: Tatiana Ayazo

If you live with axial spondyloarthritis (axSpA), you likely have several questions about the COVID-19 vaccine — and what effects it could potentially have on your condition.

Here’s the bottom line: Most rheumatologists and public health experts recommend you get vaccinated against COVID-19 if you have axial spondyloarthritis. The American College of Rheumatology states that autoimmune and inflammatory rheumatic disease patients are at higher risk for COVID-19 hospitalization and worse outcomes than the general population, and should receive the vaccine when they’re eligible.

There are no known contraindications to the COVID-19 vaccine (reasons to not get it) for axial spondyloarthritis patients.

“I encourage all my axial spondyloarthritis patients to get COVID-19 vaccine as soon as it is available to them,” says Samar Gupta, MD, FACR, a rheumatologist at Michigan Medicine. “These patients are often on immunosuppressive medications, which may make them susceptible to COVID-19.”

Axial spondyloarthritis (axSpA) is a form of inflammatory arthritis that causes pain predominantly in the lower back and sacroiliac joints, where the spine connects with the pelvis (though it can cause pain in other joints too). AxSpa is an umbrella term that includes two subtypes:

Patients with axial spondyloarthritis who experience structural damage in their spine or sacroiliac joints that can be seen on X-rays have what’s known as radiographic axSpA (r-axSpA) — or ankylosing spondylitis. Those who do not have these structural changes but have axSpA based on symptoms and other clinical features have non-radiographic axial spondyloarthritis (nr-axSpA).

Here’s everything you need to know about getting the COVID-19 vaccine if you have axial spondyloarthritis.

Is It Safe to Get the COVID-19 Vaccine with Axial Spondyloarthritis?

Yes, it is safe and encouraged to get the COVID-19 vaccine if you have axial spondyloarthritis. Of course, it’s important to discuss the COVID-19 vaccine with your doctor if you have questions, as everyone’s case is unique — but most experts recommend that axial spondyloarthritis patients receive the vaccine as soon as possible.

In fact, it may be particularly important to get the COVID-19 vaccine if you have axSpA, since immunosuppressive drugs may make you more likely to experience severe disease. Adults of any age who are immunocompromised may have a higher risk of severe illness from COVID-19 and may remain infectious for a longer period of time, per the U.S. Centers for Disease Control & Prevention. (Research is mixed and ongoing; current data suggests coronavirus complications may have more to do with age, other comorbidities, and taking steroid medications than axSpA alone.)

Axial spondyloarthritis is considered a combination of autoimmune and inflammatory disease. Having an autoimmune disease in and of itself can decrease your body’s ability to ward off infection. That’s because your body can become so preoccupied with mistakenly attacking your own cells that it doesn’t fight off invaders as effectively as it should.

Many patients who take medications that affect immune system function are concerned that certain vaccines could give them the virus. This could theoretically occur with vaccines like the MMR vaccine for measles and mumps, which is a “live” vaccine. That means it is a weakened form of the virus intended to cause a harmless infection that your immune system rapidly eliminates.

However, none of the COVID-19 vaccines currently authorized in the U.S. — Pfizer, Moderna, and Johnson & Johnson — are live vaccines. You cannot get coronavirus from the COVID-19 vaccine. It is safe for people with axSpA, including those who take immunosuppressant medication.

Having axial spondyloarthritis or taking medications to treat it is not a reason to skip getting the vaccine. According to the U.S. Centers for Disease Control and Prevention, the only contraindications to receiving the COVID-19 vaccine are:

  • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine.
  • Immediate allergic reaction of any severity to a previous dose or known (diagnosed) allergy to a component of the vaccine. See the ingredients in each vaccine here.

If you have had an immediate allergic reaction to any other vaccine or injectable therapy — like injectable biologics — it is a precaution but not a contraindication to receiving the vaccine, per the CDC. However, you will need to be monitored for 30 minutes after getting the vaccine rather than 15 minutes. For more information, refer to our full guide: Can You Safely Get a COVID-19 Vaccine If You Have a History of Allergic Reactions?

Will the COVID-19 Vaccine Be Less Effective if You Have Axial Spondyloarthritis?

How the COVID-19 vaccine works in rheumatic disease patients is an ongoing area of research, and experts are currently investigating whether or not these individuals have a less robust response to the vaccine (and thus less protection from the coronavirus).

In its guidance about the COVID-19 vaccine, the American College of Rheumatology notes that the expected response to COVID-19 vaccination for many autoimmune and inflammatory rheumatic disease patients on systemic immunomodulatory therapies is likely to be reduced compared to the general population, but this is not a reason to skip the vaccine.

Even if you have a somewhat more reduced response to the vaccine than another individual, some protection from the virus is better than none — and could help prevent hospitalization or even death.

“In recent studies, it has been shown that SARS-CoV-2 mRNA vaccines [like those from Pfizer and Moderna] lead to development of antibodies in immunosuppressed patients with chronic inflammatory conditions, including spondyloarthropathies like ankylosing spondylitis, without considerable side effects or induction of disease flares,” says Dr. Gupta.

That said, it’s still important to follow mitigation efforts after getting the vaccine. For more information, here’s what immunocompromised people should know about the recommendations for fully vaccinated people.

Are There Any Specific Vaccine Side Effects to Be Aware of with Axial Spondyloarthritis?

Some effects of the COVID-19 vaccine could resemble those of an axSpA flare. Monitor your symptoms before and after getting the vaccine, and talk to your doctor if you have any questions or concerns.

Symptoms of axial spondyloarthritis include the following, per the Mayo Clinic:

  • Pain and stiffness in your lower back and hips (especially in the morning or after periods of inactivity)
  • Neck pain
  • Fatigue
  • Pain in other parts of the body such as:
    • The places where your tendons and ligaments attach to bones, mainly in your spine, but sometimes along the back of your heel
    • The cartilage between your breastbone and ribs
    • Your hip and shoulder joints

Generally, these symptoms can be distinguished from side effects of the vaccine, though some may overlap. The CDC lists the following common side effects of the COVID-19 vaccine:

  • Pain on the arm where you got the shot
  • Redness on the arm where you got the shot
  • Swelling on the arm where you got the shot
  • Tiredness
  • Headache
  • Muscle pain
  • Chills
  • Fever
  • Nausea

“The pain and the fatigue from the COVID-19 vaccine can overlap with axial spondyloarthritis symptoms, but the vaccine symptoms tend to be more widespread and usually not localized to singular joints,” says rheumatologist John Miller, MD, Instructor of Medicine in the Division of Rheumatology at Johns Hopkins Medicine. “Pain from the vaccine can come on fairly quickly, lasts a couple days, and then goes away as quickly as it started.”

For more information on distinguishing disease flares from vaccine side effects, here’s our guide on what to do after getting a COVID-19 vaccine if you’re immunocompromised or have an autoimmune condition.

Could the COVID-19 Vaccine Cause a Disease Flare?

Although the ACR guidance notes that there’s a chance for autoimmune and inflammatory rheumatic disease flare or disease worsening after COVID-19 vaccination, experts agree it’s not very likely — and that the benefit of getting vaccinated outweighs the risk.

“There have been a couple of reports in which we can see flares develop afterward, but generally speaking, those are few and far between,” says Dr. Miller. “From a public health perspective, we still think it’s better to get vaccinated. And it’s definitely safer to get vaccinated than to have a COVID-19 infection.”

What’s more, disease activity or severity is not a contraindication to getting the vaccine, according to the ACR guidance. In other words: If your axial spondyloarthritis disease activity is active, you can still get the vaccine.

If you have any concerns about getting the vaccine during a disease flare, talk to your doctor.

In extreme cases — say, you’re hospitalized or taking a very high level of steroids that you’ll be able to taper off of soon — your doctor may recommend you wait to receive the vaccine to improve your body’s response. Ideally, you would have the opportunity to get to lower disease activity, transition to a non-steroid therapy, and decrease your dosage of steroids under your doctor’s guidance before receiving the COVID-19 vaccine (which should then take place as soon as possible).

Do You Need to Modify Axial Spondyloarthritis Medications Before or After Getting the Vaccine?

It’s not likely: The ACR guidance does not recommend holding any biologics used for axial spondyloarthritis before or after receiving the vaccine.

“If you are taking a medication for axial spondyloarthritis, you should discuss the timing of COVID-19 vaccination with your rheumatologist,” says Dr. Gupta. “But it is recommended, in most cases, that patients who are to receive a COVID-19 vaccine continue their biologic or oral therapies for axial spondyloarthritis.”

The ACR does recommend that a few certain medications be temporarily stopped, or that the vaccine should be timed around dosing schedules, in order to help improve vaccine effectiveness — but these medications are not commonly used to treat axial spondyloarthritis. They include:

  • Methotrexate
  • JAK inhibitors (ex: Xeljanz, Olumiant, Rinvoq)
  • Abatecept (Orencia)
  • Rituximab (Rituxan)
  • Cyclophosphamide infusions

Questions About Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Many axSpA patients regularly take NSAIDs, such as ibuprofen, naproxen, and prescription versions, to treat their symptoms. They are considered a first-line treatment for axSpA.

At the same, time, many people take NSAIDs to treat vaccine-related side effects, such as fever and pain. But the CDC has recommended that people do not take NSAIDs before vaccination for the purpose of trying to prevent vaccine side effects, though they can take them after to treat side effects.

“There have been questions of whether NSAIDs may reduce vaccine response, so current recommendations are to avoid using them as a pre-medication,” says Dr. Gupta. “No specific studies of the use of acetaminophen or NSAIDs have been done to examine any impact on COVID‐19 vaccine immunogenicity [effictiveness] in adults.”

But if you take NSAIDs regularly to treat axSpA, should you avoid taking them before getting the vaccine? The answer: Talk to your doctor about whether or not you should hold them temporarily — and if so, for how long.

“I always try to avoid NSAIDs if possible around the vaccine, but I’m not sure if there’s striking data that says NSAIDs have to be discontinued for prolonged periods of time,” says Dr. Miller. “If someone is using it on a regular basis, there may not always be a justification for holding NSAIDS. It’s an individual decision.”

A March 2021 study published in the Journal of Virology found that NSAID treatment reduced the antibody production in response to SARS-CoV-2 infection in mice. Antibodies are proteins that the immune system uses to protect you from viruses like SARS-CoV-2, and they are created when you get infected with COVID-19 or receive the COVID-19 vaccine. However, much more research is needed to determine what the results of this research might mean for humans and the COVID-19 vaccine.

Until more clinical guidance is available, the decision about whether or not to hold routine NSAIDs before or after your COVID-19 vaccine will need to be made on a case-by-case basis with your doctor.

Are People with Axial Spondyloarthritis at Greater Risk for COVID-19?

This is an ongoing area of research.

Those with axial spondyloarthritis don’t appear to have a higher risk of contracting COVID-19 than the general population. That said, some data shows that having inflammatory rheumatic disease could lead to a higher risk of serious complications from COVID-19 — and immunosuppressive medications may also affect your risk of contracting or getting severely ill from COVID-19.

“Existing data suggests that patients with spondyloarthropathies have similar rates of COVID-19 infection as the general population,” says Dr. Gupta. “The likelihood of poor outcomes from COVID-19 is driven by risk factors associated with axial spondyloarthritis, such as concurrent illnesses including chronic heart, lung, or kidney disease and metabolic disorders such as diabetes and obesity.”

“We do worry that untreated moderate to severe arthritis does increase the risk of worse outcomes compared to an individual who does not have a rheumatic disease,” says Dr. Miller.

For more information, check out this summary of research on inflammatory arthritis and rheumatic disease patients and their risk for COVID-19 complications.

When Can You Get a COVID-19 Vaccine with Axial Spondyloarthritis?

It will be up to your state’s guidelines. The ACR has advocated for autoimmune and inflammatory rheumatic disease patients to be prioritized for vaccination before the nonprioritized general population of similar age and sex, due to their higher risk for severe outcomes from COVID-19.

Either way, you likely don’t need to wait long: The White House recently declared that all adults in the United States will be eligible for vaccination no later than May 1, and many states are making the vaccine available to all adults sooner.

To make this possible, government officials are increasing the number of locations where people can get vaccinated (including community health centers, pharmacies, and community vaccination centers), expanding the professionals who can administer shots (including dentists, optometrists, podiatrists, veterinarians, medical students, and more), and providing tools to make it easier to find vaccines (like websites and a call center), per The White House.

Public health officials and rheumatologists advise getting the first vaccine that becomes available to you.

“The important thing is that people are moving forward with getting vaccinated,” says Dr. Miller. “We’re really seeing that patients tolerate the vaccine well and it’s such a positive step to some normalcy. We’re not there yet, but at least we’re heading in the right direction.”

Once you get your vaccine, you still need to be careful to follow standard mitigation efforts. For more information, here’s what immunocompromised people should know about the CDC recommendations for fully vaccinated people.

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Ankylosing spondylitis. Mayo Clinic. November 8, 2019. https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808.

Chen JS, et al. Nonsteroidal Anti-inflammatory Drugs Dampen the Cytokine and Antibody Response to SARS-CoV-2 Infection. Journal of Virology. March 10, 2021. doi: https://doi.org/10.1128/JVI.00014-21.

COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases. American College of Rheumatology. February 8, 2021. https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf.

Fact Sheet: President Biden to Announce All Americans to be Eligible for Vaccinations by May 1, Puts the Nation on a Path to Get Closer to Normal by July 4th. The White House. March 11, 2021. https://www.whitehouse.gov/briefing-room/statements-releases/2021/03/11/fact-sheet-president-biden-to-announce-all-americans-to-be-eligible-for-vaccinations-by-may-1-puts-the-nation-on-a-path-to-get-closer-to-normal-by-july-4th/.

If You Are Immunocompromised, Protect Yourself From COVID-19. COVID-19. U.S. Centers for Disease Control and Prevention. December 16, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/immunocompromised.html.

Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States. Vaccines & Immunizations. U.S. Centers for Disease Control and Prevention. March 5, 2021. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html.

Interview with John Miller, MD, Instructor of Medicine in the Division of Rheumatology at Johns Hopkins Medicine

Interview with Samar Gupta, MD, FACR, a rheumatologist at Michigan Medicine

Magrey MN, et al. Recognizing Axial Spondyloarthritis: A Guide for Primary Care. Mayo Clinic Proceedings. July 29, 2020. doi: https://doi.org/10.1016/j.mayocp.2020.02.007.

Measles, Mumps, and Rubella (MMR) Vaccination: What Everyone Should Know. Vaccines and Preventable Diseases. U.S. Centers for Disease Control and Prevention. January 26, 2021. https://www.cdc.gov/vaccines/vpd/mmr/public/index.html.

Possible Side Effects After Getting a COVID-19 Vaccine. COVID-19. U.S. Centers for Disease Control and Prevention. March 16, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html.

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