• Some people with lupus may be immunocompromised due to taking disease-modifying antirheumatic drugs (DMARDs).
• Immunocompromised people may be recommended to get an extra dose of COVID-19 vaccine to help their immune system develop sufficient protection.
• Booster doses of COVID-19 vaccines, recommended for all people age 12 and up, help restore protection after initial effectiveness wanes over time.

Lupus is an autoimmune disease, meaning it is caused when the immune system mistakenly attacks healthy tissues in your body. Since systemic lupus erythematosus (SLE) is often treated with immunosuppressive drugs that suppress aspects of the immune system, people with lupus may be considered immunocompromised and have a higher risk of infections. This includes infection with the coronavirus that causes COVID-19.

Studies show that, among people who are hospitalized for COVID-19 infection, people with SLE have a higher risk of death or poor outcomes than people without SLE. Because of this, it is especially important for people with lupus to take precautions against COVID-19, including getting vaccinated and receiving vaccine boosters or extra doses of vaccine as recommended.

COVID-19 Vaccines and Current Guidelines

There are several COVID-19 vaccines available. The three COVID-19 vaccines currently approved for use in the U.S are:

• Pfizer — A messenger RNA (mRNA) vaccine
• Moderna — An mRNA vaccine
• Johnson & Johnson — A viral vector vaccine

The Centers for Disease Control and Prevention (CDC) currently state that you need to complete a primary series of two doses of the same mRNA vaccine (Pfizer or Moderna), or one dose of the Johnson & Johnson vaccine to be considered fully vaccinated.

Lupus and Immune Responses to COVID-19 Vaccines

There are many treatments for lupus, but disease-modifying antirheumatic drugs and corticosteroids act by suppressing the immune system to prevent it from attacking the body. While immunosuppressive medications prevent the symptoms of lupus, they also make it harder for your immune system to fight off infections from pathogens like bacteria and viruses. For people with lupus who take immunosuppressive medications, their immune system may not respond very well to the COVID-19 vaccines.

One study of 90 people with SLE found that 29 percent had lower antibody responses to the coronavirus after the full primary series of COVID-19 vaccines compared to people without SLE. People who used any immunosuppressant medication or prednisone were more likely to have a lower vaccine response.

A review of studies found that people with SLE were less likely to have strong immune responses after COVID-19 vaccination, likely because of immunosuppressants used to treat SLE like glucocorticoids, methotrexate, mycophenolic acid, and rituximab.

Though scientists are still working to understand how COVID-19 vaccines affect people with SLE, the current research suggests that immunocompromised people, like those taking SLE medications, may not be as well protected from COVID-19 after the regular primary series of vaccinations. However, researchers are careful to emphasize that the vaccines do provide important protection, and most people with SLE should be fully vaccinated against COVID-19.

Extra Doses for Immune-Compromised People

As of January 6, the CDC updated its COVID-19 recommendations to include another vaccine dose in the primary vaccine series for “moderately or severely immunocompromised people ages 5 and older.” The CDC recommends:

• Immunocompromised people who received mRNA vaccines (Pfizer or Moderna) for their first and second dose should get an additional dose of the same vaccine 28 or more days later, for a total of three doses total in the primary vaccine series.
• People who received the Johnson & Johnson vaccine as their first dose should get one of the mRNA vaccines as a booster dose two or more months later.

The extra dose recommended for immunocompromised people is sometimes called a “booster,” but this can be confused with the booster shots that the CDC recommends for everyone. To avoid this confusion, the CDC lumps this additional shot in with the “primary series” of vaccines and refers to the “booster” vaccine as one received several months after the primary series.

Whether a person with SLE is considered moderately or severely immunocompromised depends on their individual health condition and the medications they take. The Lupus Foundation of America notes, “Many people with lupus are not immunocompromised to this degree.” Talk with your doctor to understand whether you will need additional doses of the COVID-19 vaccine.

Booster Vaccines for All Adults

Studies suggest that, even in people without autoimmune conditions, the protection offered by COVID-19 vaccines may decrease over time, requiring booster doses to prolong protection. One study showed that even though all three COVID-19 vaccines protect against severe COVID-19 and death, protection against COVID-19 infection decreases after six months. Thus, booster doses restore protection after the effectiveness of the initial vaccinations starts to wane over time.

The CDC recommends that all adults get a booster dose with one of the mRNA vaccines (Pfizer of Moderna) and people ages 12 to 17 get a booster dose of the Pfizer vaccine.

mRNA Vaccines

According to the CDC, people who received a primary series of mRNA vaccines should get another shot of one of the mRNA vaccines five or more months after the first round of vaccines. For people who received two mRNA vaccines doses in the primary series, the booster is the third dose. For immunocompromised people who received three mRNA vaccine doses in the primary series, this booster is the fourth dose.

Janssen Vaccine

The CDC recommends that people who originally received the Janssen vaccine get one of the mRNA vaccines (Pfizer or Moderna) as a booster dose two or more months after the primary series. The CDC may update these recommendations in the future.

Vaccine Timelines for People Who Are Not Immunocompromised

• Pfizer — Primary series of two shots 21 days apart, third mRNA booster five or more months later
• Moderna — Primary series of two shots 28 days apart, third mRNA booster five or months later
• Janssen — Primary series of one shot, followed by mRNA booster at least two months later

Vaccine Timelines for Immunocompromised People

• Pfizer — Primary series of two shots 21 days apart and a third mRNA dose 28 days later, mRNA booster five or more months later
• Moderna — Primary series of two shots 28 days apart and a third mRNA dose 28 days later, mRNA booster five or more months later
• Janssen — Primary series of one shot, followed by mRNA booster at least two months later

Modifying Lupus Treatments During COVID-19 Vaccination

The American College of Rheumatology suggests people taking certain immune-suppressing drugs can change the timing of medication during vaccination so that the immune system creates a stronger response against the COVID-19 virus. The college lists these recommendations in a clinical guidance summary. Always talk with your rheumatologist before changing your medication schedule.

COVID-19 Vaccines Are Safe for People With Lupus

People with SLE may feel concerned that COVID-19 vaccines can trigger disease flares. Fortunately, recent studies show that the risk of flares after the COVID-19 vaccines are low. One study of people with SLE found that eight people out of 79 reported mild or moderate flares after being fully vaccinated, and only one person reported a severe flare.

Another study questioned nearly 700 people with SLE who received at least one dose of a COVID-19 vaccine, and found that 3 percent of people reported an SLE flare within three days after vaccination. The authors noted that the symptoms of an SLE flare are similar to common side effects from the vaccines, so the number of true flares is likely lower than reported.

Researchers are still working to understand how COVID-19 vaccine boosters affect people with SLE and other autoimmune diseases. One research group is currently recruiting for a clinical trial to study just that. In the meantime, experts generally agree that COVID-19 vaccines are safe for people with SLE.

Talk To People Who Understand

MyLupusTeam is the social network of over 203,000 people with lupus and their loved ones. On MyLupusTeam, members come together to ask questions, give advice, and share their stories with others who understand life with lupus.

Have you been vaccinated against COVID-19? Do you still have questions about COVID-19 vaccines, extra doses, or boosters? Comment below or share your story on your MyLupusTeam.