COVID Vaccine Fourth Dose Guidance
Updated March 30, 2022
The physicians of Arthritis & Rheumatism Associates (ARA) are aware of the latest CDC COVID vaccination recommendations. Based on the updated guidelines, some of our patients may be eligible to receive a 2nd booster dose of the COVID vaccine.
In August 2021, the CDC recommended that moderately to severely immunocompromised patients receive a 3rd Moderna or Pfizer COVID vaccine dose no sooner than 28 days after the 2nd to complete the primary vaccine series. Due to the surge of COVID cases from the Omicron variant last December, the CDC in early January 2022 updated guidelines for immunocompromised patients that made them eligible for a 4th dose (1st booster dose). Those who received the J&J vaccination as the primary dose were advised to receive an additional primary dose of either Moderna or Pfizer vaccine as soon as 4 weeks after the 1st dose. They were eligible to receive a booster dose of either Moderna or Pfizer as soon as 2 months after the 2nd dose.
For all patients ≥ 50 years, particularly those ≥ 65 and those 50 and older with underlying medical conditions which make them more susceptible to severe COVID, the CDC now recommends a 2nd booster. Patients can receive their 2nd Moderna or Pfizer booster as soon as 4 months after their 3rd dose (1st booster dose). Patients who received J&J as their primary and booster doses are eligible to receive a 2nd booster dose as soon as 4 months after the last.
FDA has authorized a “mix-and-match” approach for the booster doses, which means that one can choose either a booster of the same vaccine as the primary vaccine series or a dose of the other available mRNA vaccine. ARA physicians support the American College of Rheumatology recommendation that patients who received the J&J vaccine choose a booster dose of an mRNA-based vaccine (either Moderna or Pfizer).
The Moderna COVID vaccine is available for eligible patients (see above) at select ARA locations (Frederick, Rockville, Olney, Wheaton, Chevy Chase, and Fairfax). If you would like to make an appointment at one of these locations, please request one through your patient portal. We do not recommend calling to make an appointment.
At this time, it is not required to get a letter for clearance to get a 4th mRNA vaccine dose. If you are asked for a letter, one can be provided to you through your patient portal.
Medication & COVID-19 Vaccines
For our patients who have not yet had an initial vaccination, the physicians of ARA encourage our patients to obtain any of the mRNA COVID-19 vaccines (Pfizer or Moderna), which are preferred at this time based on the American College of Rheumatology guidance, partly due to the availability of supplemental doses for the mRNA vaccines.
We support the guidance from the American College of Rheumatology regarding how to take various medications around the time of COVID-19 vaccinations:
If you take ibuprofen, naproxen, other NSAIDs, or Tylenol, and your rheumatologic disease is doing well, do not take them for 24 hours prior to vaccination (no restrictions on use post-vaccination).
If you take any of the following medications, and your rheumatologic disease is doing well, do not take this medication for 1 week after each dose of the COVID-19 vaccine:
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Xeljanz (tofacitinib) |
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Rinvoq (upadacitinib) |
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Olumiant (baricitinib) |
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Cellcept (mycophenolate) |
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Cyclosporine (oral) |
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Tacrolimus (oral) |
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Lupkynis (voclosporin) |
If you take methotrexate and your rheumatologic disease is doing well:
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Do not take methotrexate for 1 week after each of the mRNA vaccine doses (Pfizer, Moderna) Do not take methotrexate for 2 weeks after single-dose vaccine (Johnson & Johnson) |
If you take the following medications, contact ARA when you are nearing the time of your COVID-19 vaccination to plan scheduling the doses:
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Orencia (abatacept) |
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Rituxan (rituximab) |
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Cyclophosphamide intravenous only (Cytoxan) |
If you take the following medications, you do not have to change your medication dosing schedule around the time of your initial COVID-19 vaccination (for advice about supplemental vaccine doses see the different list):
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Actemra |
Guselkumab (Tremfya) |
Sarilumab (Kevzara) |
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Adalimumab (Humira) |
Humira |
Secukinumab (Cosentyx) |
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Anakinra (Kineret) |
hydrocortisone |
Simponi |
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Arava (leflunomide) |
Hydroxychloroquine (Plaquenil) |
Simponi Aria |
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Azathioprine (Imuran) |
Ilaris |
Skyrizi |
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Belimumab (Benlysta) |
Imuran |
Stelara |
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Benlysta |
Infliximab (Remicade, Inflectra, Renflexis) |
Sulfasalazine |
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Canakinumab (Ilaris) |
Ixekizumab (Taltz) |
Taltz |
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Certolizumab (Cimzia) |
Kevzara |
Tocilizumab (Actemra) |
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Cimzia |
Kineret |
Tremfya |
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Cosentyx |
Leflunomide |
Ustekinumab (Stelara |
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Cyclophosphamide oral only (Cytoxan) |
Prednisone |
Zoledronic acid (Reclast) |
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Cytoxan (oral only) |
Prolia |
|
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Denosumab (Prolia) |
Reclast |
|
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Enbrel |
Remicade |
|
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Etanercept (Enbrel) |
Rizankizumab (Skyrizi) |
|
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Evenity |
Romosozumab (Evenity) |
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|
|
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Holding medications around the time of supplemental dose of vaccine. If you are taking one of these medications or were taking them when you received your initial mRNA vaccination. If your rheumatologic disease is doing well, do not take any of the following medications for 1-2 weeks after supplemental vaccination, then restart taking them:
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Arava (leflunomide) |
Methotrexate (Otrexup, Rasuvo, Rheumatrex) |
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Azathioprine (Imuran) |
Mycophenolate (Cellcept) |
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Apremilast (Otezla) |
Olumiant (baricitinib) |
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Belimumab (Benlysta) |
Orencia (abatacept) |
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Benlysta |
Otezla |
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Cellcept |
Rinvoq (upadacitinib) |
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Cyclophosphamide (Cytoxan) |
Rituxan (rituximab) |
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Cyclosporine |
Sulfasalazane |
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Cytoxan |
Tacrolimus (oral) |
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Imuran |
Voclosporin (Lupkynis) |
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Leflunomide |
Xeljanz (tofacitinib) |
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Lupkynis |
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If you are taking one of these medications (or were taking them when you received your initial mRNA vaccination) then you should obtain a supplemental dose of mRNA vaccine:
|
Actemra |
Cimzia |
Ilaris |
Olumiant (baricitinib) |
Simponi Aria |
Xeljanz (tofacitinib) |
|
Adalimumab (Humira) |
Cosentyx |
Imuran |
Orencia (abatacept) |
Skyrizi |
|
|
Anakinra (Kineret) |
Cyclophosphamide (Cytoxan) |
Infliximab (Remicade, Inflectra, Renflexis, etc.) |
Prednisone and methylprednisolone |
Stelara |
|
|
Arava (leflunomide) |
cyclosporine |
Ixekizumab (Taltz) |
Remicade |
Sulfasalazine |
|
|
Azathioprine (Imuran) |
Cytoxan |
Kevzara |
Rinvoq (upadacitinib) |
Tacrolimus (oral) |
|
|
Belimumab (Benlysta) |
Enbrel |
Kineret |
Rituxan (rituximab) |
Taltz |
|
|
Benlysta |
Etanercept (Enbrel) |
Leflunomide |
Rizankizumab (Skyrizi) |
Tocilizumab (Actemra) |
|
|
Canakinumab (Ilaris) |
Guselkumab (Tremfya) |
Lupkynis |
Sarilumab (Kevzara) |
Tremfya |
|
|
Cellcept |
Humira |
Methotrexate (Otrexup, Rasuvo, Rheumatrex) |
Secukinumab (Cosentyx) |
Ustekinumab (Stelara) |
|
|
Certolizumab (Cimzia) |
Hydrocortisone (oral) |
Mycophenolate (Cellcept) |
Simponi |
Voclosporin (Lupkynis) |
|
Reference link: American College of Rheumatology COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases.