Updated Vaccination Guidance for Patients with Rheumatic and Musculoskeletal Diseases

The American College of Rheumatology (ACR) announced updated vaccination guidance for children and adults with rheumatic and musculoskeletal diseases (RMDs), including expanding indications for certain vaccines for those receiving immunosuppresive therapy, medication management at the time of vaccination, and vaccination delay.

“Patients worry about the safety of vaccines and the potential for inducing a disease flare. Providers are concerned whether rheumatic diseases and the medications used to treat them could blunt the effectiveness of vaccines,” Anne R. Bass, MD, Professor of Clinical Medicine, Hospital for Special Surgery and Weill Cornell Medicine in New York stated. “They also want to know whether certain vaccines should be given to protect rheumatology patients who are outside the age range for which they are typically recommended. This guideline was designed to address these issues.”

Expanded indications for specific vaccines in patients on immunosuppression:

For patients with RMD aged 65 years or older who are currently on immunosuppressive medication, the pneumococcal vaccination is strongly recommended. The recombinant zoster vaccine is also strongly recommended for all adult patients on immunosuppressive medication.

An HPV vaccine is conditionally recommended for patients between the ages of 26 and 45 if they were not previously vaccinated. For all patients aged 65 years or older, and adults between the ages of 18 and 65 who are currently receiving immunosuppressive medication, a high-dose or adjuvated influenza vaccination is conditionally recommended over the regular-dose vaccine. Receiving multiple vaccinations on the same day rather than over the span of different days is conditionally recommended.

Medication management during live and non-live attenuated vaccine administration:

Investigators conditionally recommend deferring live-attenuated vaccines for patients on immunosuppressive medications as well as holding immunosuppressants for a predetermined amount of time before and 4 weeks after. In patients taking glucocorticoids, prednisone ≤ 10 mg daily is strongly recommended for both the influenza vaccination and other non-live attenuated vaccinations, regardless of disease activity. However, it is conditionally recommended to defer other non-live attenuated vaccinations for those receiving a daily dose of prednisone ≥ 20 mg.

Administering live-attenuated rotavirus vaccination to infants exposed to immunosuppressive medications in utero:

Infants exposed to a tumor necrosis factor (TNF) inhibitor in the second or third trimester may receive the rotavirus vaccine within the first 6 months of life; however, infants who were exposed to rituximab should wait to receive the vaccine until after 6 months of age.

“This new guideline recognizes that some patients, particularly very young children with autoinflammatory conditions, simply cannot stay off their medications for very long without having a severe flare of their disease,” Bass explained. “However, those patients still need to get vaccinated.”