According to the Canadian Rheumatology Association guidelines on the use of vaccinations in patients with rheumatic diseases treated with DMARDs:
1. Vaccination for influenza and pneumococcus is recommended for patients with rheumatoid arthritis before or during treatment with traditional and biologic DMARD.
Hepatitis B vaccine should be considered in high-risk groups. Zoster vaccine should be considered in high-risk groups and in rheumatoid arthritis patients who take immunosuppressive medicaitons.
2. Inactivated vaccines should ideally be administered prior to starting treatment with methotrexate and/or biologic DMARD as these medications may attenuate the immune response.
3. Live vaccines should be administered at least 2 weeks and ideally 4 weeks prior to starting treatment with biologic DMARD.
In patients currently receiving biologic therapy, treatment with the biologic should be suspended and the vaccine administered after an appropriate interval based on the half-life of the drug. Herpes zoster vaccine might be given to patients receiving methotrexate (≤ 25 mg/week) and/or low-dose corticosteroids (< 20 mg per day).
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Important facts on vaccinations in patients with the connective tissue diseases and inflammatory arthritis:
Pneumococcal vaccine in adults prevents the severe form of pneumonia when infection appears in the blood (bacteremia). It is recommended for patients on the immunosuppressive medications.
Patients on immunosuppressive therapy are at increased risk of having shingles. Having a rheumatic disease itself increases the risk of shingles two-fold. Shingle vaccine provides at least 50 % protection against infection. Shingle vaccine decreases the severity and shortens the duration of illness and prevents the development of the post-herpetic neuralgia (pain) after infection.
Shingle vaccine works well for 5 years after vaccination. Vaccine recommended with previous herpes zoster infection since the risk of recurrence is 8% over 10 years. Having shingle infection protects against recurrence for approximately a year. Person can have shingle vaccine and pneumovax at the same time.
HPV (human papilloma virus) increases the risk of some cancers such as cervical, anal, and oropharyngeal. Mid-adult women are at continued risk for acquiring HPV infection. The HPV vaccine (Gardasil 9) is recommended for females 9 to 45 years of age and for males 9 to 26 years of age. HPV vaccine has reduced efficacy if given while patient is on the immunosuppressive medications. Patients should be immunized with HPV vaccine 2-4 weeks before staring immunosuppressive medications.
Vaccines rarely, if ever, exacerbate rheumatic diseases. With few exceptions, risk benefit favours vaccination.
Live attenuated vaccines: MMR, polio, intranasal influenza, herpes zoster and BCG.
Inactivated/killed vaccines: influenza, HPV, pneumococcal PCV 12 and PPVS23, meningococcal and H. influenza B.
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