Vaccinations in Patients with Rheumatic and Musculoskeletal Diseases
Introduction
Introduction
Key Points
- Pneumococcal vaccination should be administered to all rheumatic and musculoskeletal diseases (RMDs) patients taking immunosuppressive medication.
- Recombinant zoster vaccination is recommended for RMD patients >18 years of age taking immunosuppressive medication.
- Methotrexate should be held for two weeks after influenza vaccination if disease activity allows.
- Seasonal influenza vaccination should be administered to RMD patients even if their disease is active, they are taking high-dose glucocorticoids, and/or they are on rituximab.
- In RMD patients on rituximab, vaccines other than influenza should be administered at least 6 months after the last rituximab dose.
- Infants exposed to tumor necrosis factor (TNF) inhibitors in utero should receive rotavirus vaccination in the first 6 months of life.
Glossary of Terms
Immunogenicity: The ability of a vaccine to elicit an immune response.
Reactogenicity: Typical symptoms (e.g., fever, sore arm, muscle aches) which occur shortly (days) after vaccine administration either at the site of vaccination or systemically.
Seroconversion: Development of antibodies to a pathogen, elicited by a vaccine (or infection), in the blood of an individual who previously did not have detectable antibodies.
Seroprotection: An antibody level capable of protecting against infection or disease.
Titer: Numerical value indicating the level of antibody against a particular pathogen.
Table 1. Guideline Scope
Medications
Immunosuppressive medications
(prednisone, methylprednisolone, dexamethasone, hydrocortisone)
Conventional synthetic disease-modifying antirheumatic drugs (DMARDS)
- Methotrexate
- Leflunomide
- Azathioprine
- Mycophenolate mofetil/mycophenolic acid
- Calcineurin inhibitors (cyclosporine, tacrolimus, voclosporin)
- Cyclophosphamide
Biologic DMARDS
- TNF inhibitors (etanercept, adalimumab, certolizumab, golimumab, infliximab)
- Interleukin (IL) 6 receptor inhibitors (tocilizumab, sarilumab)
- IL17 inhibitors (secukinumab, ixekizumab)
- IL12/23 inhibitors (ustekinumab)
- IL23 inhibitors (guselkumab, tildrakizumab, risankizumab)
- IL1 inhibitors (anakinra, canakinumab, rilonacept)
- T cell co-stimulation inhibitor (CTLA4-Ig/abatacept)
- B cell depleting agents (rituximab, ocrelizumab, obinutuzumab)
- BLyS/BAFF inhibitors (belimumab, tabalumab)
- Interferon alpha receptor inhibitor (anifrolumab)
Targeted synthetic DMARDS
- Janus kinase ( JAK) inhibitors (tofacitinib, baricitinib, upadacitinib, filgotinib, ruxolitinib)
Non-immunosuppressive medications
- Hydroxychloroquine
- Sulfasalazine
- Colchicine
- Apremilast
- Denosumab
- Intravenous immunoglobulin G (IVIG)
Vaccinesa
Non-live attenuated
Standard dose, high dose, adjuvanted
Pneumococcal
- Polysaccharide (PPSV23)
- Conjugate (PCV13)b
Other
- Hemophilus influenza b
- Hepatitis A
- Hepatitis B
- Human papilloma virus (HPV)
- Inactivated polio
- Meningococcus B
- Meningococcus ACWY
- Tetanus toxoid/Td/Tdap
- Typhoid (injectable)
- Zoster sub-unit (Shingrix)
Live-attenuated
- Influenza (intranasal)
- MMR
- Rotavirus
- Typhoid (oral)
- Varicella
- Yellow fever
- Zoster (Zostavax)
Rheumatic and musculoskeletal disorders
Inflammatory arthropathies
- Rheumatoid arthritis
- Psoriatic arthritis
- Ankylosing spondylitis
- Spondyloarthritis
- Enthesitis-related arthritis
- Inflammatory bowel disease-associated arthritis
- Juvenile idiopathic arthritis
Connective tissue diseases
- Systemic lupus erythematosus
- Sjogren’s syndrome
- Systemic sclerosis
- Idiopathic inflammatory myopathies
- Mixed connective tissue disease
- Undifferentiated connective tissue disease
- Antiphospholipid antibody syndrome
Vasculitides
- Granulomatosis with polyangiitis
- Microscopic polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Giant cell arteritis
- Polyarteritis nodosa
- Takayasu’s arteritis
- Cryoglobulinemic vasculitis
- Relapsing polychondritis
- Behcet’s disease
- Kawasaki’s disease
- IgA vasculitis (Henoch-Schönlein Purpura)
- Primary central nervous system vasculitis
- Goodpasture’s syndrome (anti-GBM)
- Cogan’s syndrome
- Cutaneous small-vessel vasculitis
- Rheumatoid vasculitis
- Urticarial vasculitis
Other inflammatory disorders
- Sarcoidosis
- Adult-onset Still’s disease
- Polymyalgia rheumatica
- Gout
- Pseudogout
- IgG4-related disease
- Autoinflammatory disorders
a COVID-19 vaccines were not included in this guideline because of the fast-changing face of the pandemic and related literature.
b The recently approved pneumococcal vaccines, PCV15 and PCV20, were not included in the evidence review but are discussed in the text of the guideline. Please refer to current CDC guidelines for specific pneumococcal vaccination strategies. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html
Treatment
...eatment
...es Indicated vaccinations should be given t...
...le 2. Summary of Recommendations...
...nded indications for patients with RMDs who are ta...
...ationFor RMD patients aged ≥65, and RMD patien...
...eumococcal vaccinationFor patients with RMD ag...
...varicella zoster virus (VZV) vaccination (...
...on (Gardisil)For patients with RMD aged >26...
...hold immunosuppressive medication...
...nts, holding methotrexate for 2 weeks...
...s, continuing immunosuppressive medications ot...
For RMD patients, continuing immunosupp...
...tions in patients on rituximab in order to m...
...s receiving rituximab, administerin...
...D patients receiving rituximab, deferring non...
...nister non-live attenuated vaccinations to...
...who are on the equivalent of pred...
For RMD patients who are on the equivalent of pred...
...nts on the equivalent of prednisone ≥...
...patients who are on the equivalent of p...
...to defer vaccination in patients with hi...
...h RMD, giving non-live attenuated vaccinations is...
...anaging immunosuppressive therapy at the time of l...
...atients who are taking immunosuppressive m...
...ents, holding immunosuppressive medication for an...
...minister rotavirus vaccine to infants...
...fants with second and/or third trimester antena...
...es/infants with second and/or third trimes...
...give multiple vaccinations to RMD patien...
...nts, giving multiple vaccinations on the...
...able 3. Immunosuppressive Medicatio...