In which patients with autoimmune or inflammatory conditions are you recommending a 3rd dose of the mRNA COVID vaccine?

We found that many of the patients on immune suppressive medications do not have an appropriate response to the initial 2 doses of mRNA COVID19 vaccines. At this point, I recommend a 3rd dose to all the patients on immune suppressive medications, prioritizing the ones with known low titers of SARS-CoV2 spike protein antibody. I recommend that they hold (if stable) all immune suppressive medications for at least a week after the vaccination.

To address this question, COVID-19 Vaccine Clinical Guidance Summary for patients with rheumatic and musculoskeletal diseases developed by the ACR COVID-19 vaccine clinical guidance task force was updated on August 19, 2021, to recommend a single third dose of Pfizer or Moderna COVID-19 vaccine at least 28 days after completion of the original vaccine series for all autoimmune and inflammatory rheumatic disease patients receiving any immunosuppressive or immunomodulatory therapy.