expert roundtables

Vaccination Recommendations for Patients With Rheumatoid Arthritis

by Jonathan S. Hausmann, MD, James O’Dell, MD, MACR, MACP, Alvin F. Wells, MD, PhD

Overview

Patients with rheumatoid arthritis (RA) should receive recommended vaccines prior to the initiation of immune-modulating agents. Concerns about reduced vaccine efficacy with certain disease-modifying therapies (eg, methotrexate [MTX], rituximab) should not translate to patients with RA who are forgoing recommended vaccines entirely.

Q: How can vaccine coverage rates in the RA population be improved, and what are the concerns or uncertainties about vaccine efficacy/safety in patients with RA?

Alvin F. Wells , MD, PhD

Visiting Foreign Professor, Karolinska Institute
Director, Rheumatology and Immunotherapy Center
Adjunct Assistant Professor, Duke University Medical Center
Clinical Assistant Professor, Marquette University
Franklin, WI

“MTX and rituximab have been shown to blunt vaccine efficacy, so the timing of therapy with respect to vaccine administration is important. Our standard of care is to screen patients at baseline and make sure that they are as immunocompetent as possible before we initiate disease-modifying therapy.” 

Alvin F. Wells, MD, PhD

We are very aggressive with vaccinations in the clinic. MTX and rituximab have been shown to blunt vaccine efficacy, so the timing of therapy with respect to vaccine administration is important. Our standard of care is to screen patients at baseline and make sure that they are as immunocompetent as possible before we initiate disease-modifying therapy. We actually administer pneumococcal and influenza vaccines here in the clinic, and we also check varicella titers. If the patient’s varicella titers are low, we will send that individual to a pharmacy to receive the newer killed varicella zoster vaccine. We can typically obtain insurance approval for the zoster vaccine, even if the patient is below the normal recommended age of 50 years, because that individual is on immunosuppressive therapy. I think that ensuring that patients with RA are up to date on vaccinations before adding MTX is where many rheumatologists drop the ball. Live vaccines are another concern. I would never administer a live vaccine to an individual on immunosuppressive therapy. It is also important to talk to patients with RA about the risks of contracting infectious disease from household contacts, including children who may be receiving a live virus vaccine such as the MMR vaccine, the rotavirus vaccine, and the live attenuated influenza vaccine. The risk is that the immunocompromised patient with RA will be exposed to viral shedding. Finally, there is a misconception that vaccines will cause disease flares in patients with RA, but this is not actually an issue. Vaccine-related arthralgia is not disease flare.

Jonathan S. Hausmann, MD

Instructor in Medicine
Harvard Medical School Pediatric and Adult Rheumatology
Boston Children's Hospital
Beth Israel Deaconess Medical Center
Boston, MA

“We are fortunate, from a pediatric rheumatology perspective, that most children in the United States are well immunized and have good documentation of their vaccination history.” 

Jonathan S. Hausmann, MD

We are fortunate, from a pediatric rheumatology perspective, that most children in the United States are well immunized and have good documentation of their vaccination history. So, it is fairly easy to ensure that patients have received all of their pediatric immunizations. Vaccines outside of the routine age-based recommendations for pediatric patients include PPSV23, or Pneumovax, which is recommended for children and adolescents who are immunosuppressed. The HPV vaccine is important for most patients to receive. Vaccination with 3 doses of the HPV vaccine is recommended for those of the right age (9-26 years) with autoimmune disease, or those on immunosuppressive therapy, because immune response to vaccination might be attenuated. One of the challenges that we face in our rheumatology clinic is that we do not provide most of the immunizations, with the exception of the influenza vaccine. We refer our patients to their primary care physician, but we cannot ensure that they visit their primary care doctor, that they receive the vaccinations we recommended, and that they provide us with the documentation that they were given during their next clinic visit. Another challenge is that patients may receive vaccines outside of their clinical care, such as at a pharmacy. This may be problematic when the pharmacy does not have access to the patient’s medical record and may not fully understand contraindications to vaccinations. For instance, I have had patients on anti–tumor necrosis factor agents who received a live zoster vaccine at a pharmacy. Nevertheless, there is no question about the value of appropriate vaccinations—we have all seen complications in patients who develop infectious diseases that could have been prevented from routine vaccines.

James O’Dell, MD, MACR, MACP

Stokes Shackleford Distinguished Professor
Chief, Division of Rheumatology and Vice Chair for Education, Department of Internal Medicine
Director, Internal Medicine Residency Program
University of Nebraska Medical Center
Founder and Director, Rheumatoid Arthritis Investigational Network
Omaha, NE

“I completely agree that the time to think about getting patients vaccinated is prior to initiating therapy. That said, I would never advise patients to forgo vaccination because they are receiving MTX.” 

James O’Dell, MD, MACR, MACP

I do not recommend that patients who are on immunosuppressive therapy receive a live vaccine. However, I think that the data are rather reassuring in the event that a patient inadvertently receives the live zoster vaccine while on a biologic. I completely agree that the time to think about getting patients vaccinated is prior to initiating therapy. That said, I would never advise patients to forgo vaccination because they are receiving MTX. Yes, MTX slightly decreases the response to pneumococcal and other vaccines; however, my opinion is that vaccination is still appropriate for these individuals. Recently, there has been a movement to withhold MTX for 2 weeks so that patients can be vaccinated. I do not advocate this approach, as it has the potential to undermine adherence (eg, if a 2-week hiatus is fine, why not withhold MTX even longer?). Moreover, I think that it is counterproductive because we should be most concerned about disease control, and I am cautious about going overboard with vaccine efficacy–related concerns. There are some data suggesting that having RA, irrespective of treatment, decreases one’s response to vaccines, but this is more of an academic question because patients with RA need to be vaccinated regardless of whether they might have a somewhat diminished response.

References

Baker DW, Brown T, Lee JY, et al. A multifaceted intervention to improve influenza, pneumococcal, and herpes zoster vaccination among patients with rheumatoid arthritis. J Rheumatol. 2016;43(6):1030-1037.

Centers for Disease Control and Prevention. Vaccine Recommendations and Guidelines of the ACIP. Altered Immunocompetence. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html. Accessed December 1, 2018. Garland SM, Brotherton JML, Moscicki AB, et al. HPV vaccination of immunocompromised hosts. Papillomavirus Res. 2017;4:35-38.

Garland SM, Brotherton JML, Moscicki AB, et al. HPV vaccination of immunocompromised hosts. Papillomavirus Res. 2017;4:35-38.

Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendations of the Advisory Committee on Immunization Practices. Am J Transplant. 2017;17(3):834-837.

Meroni PL, Zavaglia D, Girmenia C. Vaccinations in adults with rheumatoid arthritis in an era of new disease-modifying anti-rheumatic drugs. Clin Exp Rheumatol. 2018;36(2):317-328.

Sandler DS, Ruderman EM, Brown T, et al. Understanding vaccination rates and attitudes among patients with rheumatoid arthritis. Am J Manag Care. 2016;22(3):161-167.

Winthrop KL, Silverfield J, Racewicz A, et al. The effect of tofacitinib on pneumococcal and influenza vaccine responses in rheumatoid arthritis. Ann Rheum Dis. 2016;75(4):687-695.

Winthrop KL, Wouters AG, Choy EH, et al. The safety and immunogenicity of live zoster vaccination in patients with rheumatoid arthritis before starting tofacitinib: a randomized phase II trial. Arthritis Rheumatol. 2017;69(10):1969-1977.

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