What approach should be taken for shared decision making regarding the COVID-19 (Coronavirus Disease 2019) vaccine?

Shared Decision-Making Approach for COVID-19 Vaccination

Healthcare providers should engage patients in a structured shared decision-making process regarding COVID-19 vaccination that addresses individual risk factors, concerns, and preferences while emphasizing the vaccine's benefits for reducing morbidity and mortality. 1

Core Elements of Shared Decision-Making for COVID-19 Vaccination

Provider Responsibilities

• Rheumatology and other specialty healthcare providers are responsible for initiating discussions about COVID-19 vaccination status with their patients 1
• Providers should document vaccination details including which vaccine was administered, timing of vaccination, and whether the series was completed 1
• For unvaccinated patients, the specialty provider should share responsibility with the patient's primary care provider to ensure appropriate vaccinations are administered 1

Key Discussion Components

• Assess patient attitudes, intent, and concerns related to vaccination 1
• Discuss local COVID-19 incidence and transmission rates 1
• Review individual circumstances that may affect risk, including:
  • Disease activity and stability 1
  • Current medications and their potential impact on vaccine response 1
  • Comorbidities that might increase COVID-19 risk 1
• Evaluate patient's ability to adhere to non-pharmacologic preventive measures 1
• Address vaccine efficacy and potential safety concerns, including reactogenicity and risk of disease flare 1

Risk Assessment and Prioritization

Higher-Risk Populations

• Patients with autoimmune and inflammatory rheumatic diseases (AIIRD) are at higher risk for:
  • Incident viral infections compared to the general population 1
  • Hospitalization due to COVID-19 1
  • Worse outcomes from COVID-19 infection 1
• These higher-risk patients should be prioritized for vaccination before the non-prioritized general population of similar age and sex 1

Special Considerations for Specific Patient Groups

• For patients with psoriatic disease:
  • Systemic medications for psoriasis or psoriatic arthritis are not contraindications to mRNA-based COVID-19 vaccines 1
  • Patients should generally continue their biologic or oral therapies while receiving vaccination 1
• For pediatric patients with rheumatic conditions:
  • Engage both the patient and caregivers in the decision-making process 1
  • Develop individualized plans that consider the child's specific circumstances and safety 1

Addressing Common Patient Concerns

Vaccine Safety

• Beyond known allergies to vaccine components, there are no additional contraindications to COVID-19 vaccination for patients with rheumatic and musculoskeletal diseases 1
• The benefit of COVID-19 vaccination outweighs the potential risk for new-onset autoimmunity 1
• Potential side effects include injection site reactions, fatigue, headache, muscle pain, joint pain, chills, nausea, vomiting, and fever 2
• Rare but serious side effects include myocarditis and pericarditis, particularly in males 12-24 years of age 2

Vaccine Efficacy

• Many patients with rheumatic diseases receiving immunomodulatory therapies may have a blunted response to vaccination in magnitude and duration compared to the general population 1
• Despite potentially reduced efficacy, vaccination still provides important protection against severe disease 3

Disease Flares

• There is a theoretical risk for disease flare or worsening following COVID-19 vaccination 1
• However, the risk of COVID-19 infection generally outweighs this theoretical concern 1

Practical Implementation of Shared Decision-Making

Structured Approach

• Begin with informing patients about the need for a vaccination decision 4
• Explain the medical facts and treatment options available 4
• Elicit patient preferences, values, and goals 4
• Identify treatment options and outcomes important to the patient 4
• Facilitate the actual decision-making process 4

Timing Considerations with Medications

• For patients on immunosuppressive medications, consider optimal timing of vaccination relative to medication administration 1
• For rituximab, when possible, time administration 2-4 weeks after the second vaccine dose, provided disease is under acceptable control 1
• For cyclophosphamide, coordinate timing so infusion occurs approximately one week after each vaccine dose when feasible 1

Documentation and Follow-up

• Document the shared decision-making discussion in the medical record 1
• Schedule appropriate follow-up to address any post-vaccination concerns or side effects 1
• Monitor for disease activity changes following vaccination 1

Evidence Supporting Shared Decision-Making for Vaccination

• Shared decision-making interventions have been shown to significantly increase vaccine uptake compared to control groups (odds ratio = 1.45; 95% CI [1.17-1.80]) 5
• These interventions can also decrease decisional conflict and increase decision confidence 5
• Shared decision-making represents an ethically defensible strategy to increase vaccination rates while respecting patient autonomy 5

Practical Pitfalls to Avoid

• Avoid being overly dogmatic in following timing recommendations, as this might compromise a willing patient's ability to undergo timely vaccination 1
• Don't delay vaccination indefinitely waiting for "perfect" circumstances (e.g., completely stable disease), as these conditions may never materialize 1
• Remember that the attempt to optimize vaccine response should not result in a missed vaccination opportunity 1
• Avoid making assumptions about patient preferences or concerns without direct discussion 4