Updated: COVID-19 vaccination recommendations in RMDs

This is the lay version of the EULAR recommendations for COVID-19 vaccination in people with rheumatic
and musculoskeletal diseases. The original publication can be downloaded from the EULAR website:

Landewé RBM, Kroon FPB, Alunno A, et al. EULAR recommendations for the management and vaccination of people with rheumatic and musculoskeletal diseases in the context of SARS-CoV-2: the November 2021 update. Ann Rheum Dis. doi:10.1136/annrheumdis-2021-222006

EULAR gives advice to doctors, nurses and patients about the best way to treat and manage diseases.
Doctors, other health professionals, and patients, worked together to develop these updated
recommendations. This included doctors specialising in rheumatology, and those with expertise in infectious disease. The patients in the team ensured that the patient point of view was included.

What do we already know?
COVID-19 is the infection caused by the SARS-CoV-2 virus. The outbreak of this virus was declared a
pandemic in March 2020 by the World Health Organization. EULAR published its first recommendations on
how to manage rheumatic and musculoskeletal diseases (RMDs) in June 2020. This was provisional advice early on in the pandemic, and was based on expert opinion. The first recommendations were made before vaccines for COVID-19 were available, and included general public health measures and precautions for people with RMD without COVID-19 infection. Since that time, a lot of information and data has been collected on COVID-19, and several vaccines have been approved.

EULAR updated the original recommendations in July 2021. Two new points to consider were added in
November 2021. These were based on developments around additional vaccination doses. However, at this time, the points to consider are not given the same status as a recommendation. This is because the
supporting evidence is not yet robust enough.

What do the recommendations say?
In total, there are five overarching principles, nine recommendations, and two points to consider. The
principles emphasise that – in general – people with RMDs do not have a higher risk of getting COVID-19
than people without RMDs, and do not generally have a worse outcome when they do get infected. The
treatment of COVID-19 in people with RMDs should be mainly done by expert in infectious disease. But
rheumatologists are the experts for their patients’ RMD treatments, and should be involved in any decision to maintain or discontinue them because of COVID-19. Unless it is recommended in an official guideline or is done as part of a clinical trial, immunomodulatory or immunosuppressive drugs should not be used off-label to treat COVID-19.

Each recommendation is based on the best current knowledge from studies of scientific evidence or expert opinion. The more stars a recommendation has the stronger the evidence is. However, recommendations with limited scientific evidence may be important, because the experts can have a strong opinion even when the published evidence may be lacking.

One star (*) means it is a recommendation with limited scientific evidence.
Two stars (**) means it is a recommendation with some scientific evidence.
Three stars (***) means it is a recommendation with quite a lot of scientific evidence.
Four stars (****) means it is a recommendation supported with a lot of scientific evidence.


  • People with RMDs should comply with all infection prevention and control measures, both before and after COVID-19 vaccination.****
    If you have an RMD, you are strongly advised to following the public health guidance in your country. This applies even after you have received your COVID-19 vaccine.
  • People with RMDs should have a COVID-19 vaccination.***
    You are strongly advised to get vaccinations against COVID-19. If you have an RMD, you can receive
    any of the COVID vaccines approved in your country.
  • If you have been vaccinated against COVID-19, you should continue your usual RMD treatment unchanged.***
    If you have an RMD and have been vaccinated against COVID-19, you should continue with treatment for your RMD as usual. If you have not been vaccinated you should also continue taking your RMD treatment. However, if you are unvaccinated you should be aware that some rheumatic medicines have been associated with an increased risk of severe COVID-19.
  • If you develop suspected or confirmed COVID-19 while taking long-term glucocorticoids you
    should continue with your medicine.***

    There is some evidence that pausing or discontinuing glucocorticoids (corticoids) might cause your RMD to flare. This in itself may contribute to worse outcomes if you get COVID-19. For the time being, the advice for people taking long-term glucocorticoid medicines for their RMD is to continue on treatment even if you catch COVID-19.
  • If you are taking rituximab, you may need to postpone your next cycle if you get COVID-19.***
    Rituximab is a medicine used for RMDs that works by reducing numbers of B cells – part of your
    immune system. There is some evidence that people taking these kind of medicines have a higher risk of developing severe COVID-19. They also do not have such a good response to vaccination. Because of this, you and your healthcare team may consider postponing your next treatment cycle if you have an active COVID-19 infection.
  • People with RMDs who initially have mild COVID-19 symptoms but experience worsening should immediately seek the advice of an expert in treating COVID-19.***
    A small number of people with COVID-19 will experience a more severe infection. Some people might
    need ventilation, or medicines to fight the symptoms. Although rheumatologists will be familiar with
    some of these medicines, the diagnosis and management of severe COVID-19 should be done by an
    expert in infectious disease.
  • Check your general vaccination status and make sure your protection is up to date, especially for pneumococci and influenza.****
    EULAR published recommendations in 2019 for the general vaccinations that people with RMDs should have. To protect yourself you should make sure all your vaccinations are up to date – especially for pneumococcal disease (pneumonia) and influenza (the ‘flu).
  • If you have an RMD but are not yet using immunomodulatory or -suppressive treatment, you should have your COVID-19 vaccination before starting any new treatment if possible.***
    If you are going to start taking immunomodulatory or immunosuppressive treatments for your RMD, it is recommended that you have your COVID-19 vaccine first. This will depend on your individual
    circumstances, and the final decision is at the discretion of you and your rheumatologist.
  • If you are using rituximab or another B-cell depleting therapy, your COVID-19 vaccine should be scheduled to optimise the effect of the vaccine.***
    B-cell depleting medicines (e.g. rituximab) work by reducing numbers of B cells – part of your immune
    system. There is evidence that people taking these kind of medicines may not have such a good
    response to vaccination. Full evidence is still emerging around this, and it is not possible at this time for EULAR to recommend a particular time that should be left between a treatment cycle and vaccination. This will depend on your individual circumstances, and the final decision is at the discretion of you and your rheumatologist.

Points to consider

  • EULAR supports the use of third primary doses in selected groups of people.****
    There are concerns that people taking certain immunosuppressive or immunomodulatory drugs may not
    get a good enough protective response to COVID-19 vaccination. There is not yet any evidence
    available to identify who might benefit from a third primary dose of a COVID-19 vaccine. At this time,
    some healthcare authorities have recommended the use of a third dose of your original vaccine, and
    EULAR supports this approach. This is different to a booster dose, may use a different vaccine to that
    given in the original two doses.
  • EULAR supports the use of booster doses.***
    There are concerns that the protection provided by vaccines against severe COVID-19 decreases
    gradually over time. Not enough time has yet passed to know what level of protection might be expected
    4–6 months after the primary course. Taking a precautionary position, several healthcare authorities
    have recommended the use of a booster, and EULAR supports this approach.

Overall, these recommendations emphasise that vaccination is the key measure of prevention of COVID-19 for people with RMDs. EULAR hopes that these updated recommendations will help support healthcare
professionals to make decisions about COVID-19 prevention and vaccination, and to continue to treat
people’s underlying RMDs. The recommendations are not intended to over-rule any existing guidelines that there might be in your country, but can be used alongside them.

If you have any questions or concerns about your disease or your medication, you should speak to a health professional involved in your care.

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