DMARD pause after COVID-19 boosters? New trial challenges earlier guidance

Clinical takeaway: Avoid routinely pausing TNF inhibitors, IL-17 inhibitors, abatacept, or JAK inhibitors solely to improve COVID-19 booster responses in patients with inflammatory arthritis. These findings do not address whether to hold methotrexate or rituximab.

Earlier American College of Rheumatology guidance recommended briefly holding JAK inhibitors and subcutaneous abatacept after COVID-19 vaccination, if disease activity allowed, to improve immune responses. There was no consensus on interrupting TNF or IL-17 inhibitors.

The COVER randomized trial now challenges the rationale for routine interruption of these therapies. A two week pause increased arthritis flares without significantly improving antibody responses.

Researchers randomized 840 adults with rheumatoid arthritis, psoriatic arthritis, or axial spondyloarthritis to continue or temporarily hold stable treatment with a TNF inhibitor, IL-17 inhibitor, abatacept, or JAK inhibitor. All had completed a primary mRNA COVID-19 vaccine series.

At six weeks, antibody levels increased approximately fivefold in both groups. No significant benefit from holding treatment emerged overall or within any medication class. Although abatacept and JAK inhibitors were associated with weaker responses than IL-17 inhibitors, briefly stopping them did not improve those responses.

Patients who paused treatment had more than twice the odds of reporting a flare or disease worsening as those who continued, particularly among JAK inhibitor users. Among 509 participants completing an interim flare questionnaire, clinically meaningful worsening occurred in 21.1% who paused treatment versus 9.1% who continued. The excess worsening was concentrated in the first one to two weeks, with no sustained difference between groups at six weeks.

The trial measured antibody responses rather than protection against COVID-19 infection or severe illness.

“Given the increased flare risk and absence of humoral immunogenicity benefit, these findings do not support routine temporary interruption for COVID-19 vaccine optimization,” the authors concluded.

Source: Curtis JR, et al. (2026 Oct 5) JAMA Intern Med. Temporary cessation of DMARD therapy and COVID-19 supplemental dose vaccine immunogenicity in patients with inflammatory arthritis: The COVER randomized clinical trial