Vaccinations and Rheumatoid Arthritis

When you have rheumatoid arthritis (RA), you may worry about getting vaccines. After all, RA involves a malfunctioning immune system, and vaccines work by activating the immune system. It is fair to wonder whether the combination of the two effects may be harmful or contradictory.

In many cases, it is absolutely safe to be vaccinated if you have RA, but there are exceptions and a few precautions you may need to take.

Benefits of Vaccination

Both RA and the immunosuppressant drugs used to treat RA may increase your susceptibility to vaccine-preventable diseases like influenza, shingles, pneumococcal pneumonia, and others. Some studies suggest that the risk may be as high as two-fold compared to people without RA.

Moreover, if your RA is severe, you are more likely to experience frequent flares and severe infections compared to those who have their condition under control.

Vaccines are beneficial to people with RA as they reduce the risk of getting infections and complications that can arise from these infections.

Types of Vaccines

Vaccines work by exposing your body to either an infectious organism (pathogen) or a component of a pathogen. The exposure induces a pathogen-specific immune response in the form of protective antibodies. Armed with these antibodies, the body can fight off the pathogen and prevent it from establishing an infection.

When you have RA, the type of vaccine you get matters. Some are perfectly safe to use, whereas others may need to be avoided as a precaution.

Live Attenuated Vaccines

Live attenuated vaccines contain live weakened pathogens that are unable to cause disease. However, these vaccines generally aren't recommended for people with immunosuppression, including those on immunosuppressive RA therapy.

This is because a live vaccine can in theory revert to its natural virulent state. If this occurs in a person who is immunosuppressed, it may cause the very disease that it was meant to prevent. The risk of this occurring is extremely low.

Despite these theoretical concerns, there are live attenuated vaccines generally recommended for people with immunosuppression.

There are six live attenuated vaccines approved for use in the United States:

• Nasal flu vaccine
• Measles, mumps, and rubella (MMR) vaccine
• Chickenpox vaccine
• Oral typhoid vaccine
• Yellow fever vaccine
• Rotavirus vaccine

Safe Vaccines

Other types of vaccines don't contain a live virus and therefore can't cause an infection. These are considered safe for people with RA and other autoimmune diseases, including those on immunosuppressant drugs.

The types of non-live vaccines are broadly classified as follows:

• Inactivated vaccines: These contain killed pathogens and include vaccines for hepatitis A, influenza (injection only), and rabies.
• Subunit, recombinant, polysaccharide, and conjugate vaccines: These use specific pieces of a pathogen for a more targeted immune response and include vaccines for hepatitis B, human papillomavirus (HPV), meningococcal disease, pertussis (whooping cough), and shingles (herpes zoster).
• Toxoid vaccines: These use a chemically modified toxin from a pathogen, such as toxoids used to prevent diphtheria and tetanus.

COVID-19 and New Vaccine Types

Several COVID-19 vaccines—some on the market and some still in development—use novel vaccine platforms. Among them:

• Moderna and Pfizer-BioNTech COVID-19 vaccines are both messenger RNA (mRNA) vaccines. These work by delivering genetic coding to cells to "teach" them how to build COVID-19 proteins that provoke the immune response.
• Johnson & Johnson COVID-19 vaccine is a vectored vaccine that uses a modified, harmless cold virus (adenovirus 26) to deliver genetic coding to cells to build COVID-19 proteins.
• Novavax COVID-19 vaccine is a protein-based subunit vaccine that uses a custom-made spike protein that mimics the natural spike protein in the SARS-CoV-2 virus. The protein is combined with an adjuvant to boost the immune response to the vaccine.

Other vaccine candidates in development are based on these and other vaccine platforms.

Thus far, there is no reason to believe that any of the approved vaccines pose a threat to people with compromised immune systems, including those with RA. The benefits of the COVID-19 vaccination are largely believed to outweigh the risks.

Vaccine Concerns

To ensure that vaccines are safe and effective for people with RA, considerations need to be made on a case-by-case basis.

Timing

The best time for people with RA to receive vaccines depends on the level of disease activity and which treatments they're currently receiving.

Vaccination is generally most effective when a person is in remission. This means not experiencing an active flare nor undergoing extensive treatment (such as systemic corticosteroids) to manage flares.

For example, if you are being treated with high-dose prednisone, vaccination may not produce a strong immune response, leaving you unprotected. However, if you are on low-dose prednisone, you can still generate good protection from vaccination.

Vaccines and DMARDs

When it comes to live attenuated vaccines, caution should be used for people taking disease-modifying anti-rheumatic drugs (DMARDs).

DMARDs are a category of otherwise unrelated drugs that can slow disease progression in people with RA. These include immunosuppressants and biologic drugs such as:

• Actemra (tocilizumab)
• Arava (leflunomide)
• Azulfidine (sulfasalazine)
• Cimzia (certolizumab pegol)
• Enbrel (etanercept)
• Humira (adalimumab)
• Methotrexate
• Plaquenil (hydroxychloroquine)
• Remicade (infliximab)
• Simponi (golimumab)

For example, it is recommended that people taking methotrexate skip at least one (and sometimes two) doses after flu vaccination to ensure an ample immune response.

On the other hand, some medications may have no impact on vaccination. One study found that Actemra didn't interfere with the response to the flu vaccine in people with RA.

The decision as to whether you should receive a live vaccine or take a break from DMARDs is an important one. You and your healthcare provider should work together to decide what is right for you.

Vaccine Recommendations

The benefits of vaccinations almost always outweigh the risks in people with RA. Even so, experts recommend the following precautions:

• Get vaccines updated before starting DMARDs whenever possible.
• Avoid vaccinations during flares.
• Live attenuated vaccines can be considered after careful consultation with your healthcare provider.
• If you took biologics during the second half of pregnancy, your baby shouldn't receive a live attenuated vaccine until they're 6 months old.

The vaccine recommendations for people with RA are summarized in the following table. As there are currently no official U.S. guidelines, those recommended by the European Alliance of Associations for Rheumatology (EULAR) are listed below. They include alternative approaches like passive immunization, in which you receive antibodies from a donor to protect against a disease (rather than getting a vaccine). The ACR's COVID-19 vaccine recommendation is also included.

Frequently Asked Questions

Which specific vaccines should I avoid if I have RA?

People with RA should avoid the live FluMist vaccine for influenza. Other live attenuated vaccines include those for measles, mumps, and yellow fever. Some of these may be appropriate for those with RA, but you should discuss the risks and benefits with your healthcare provider.

Can vaccines trigger RA flares?

There have been unproven reports of vaccines triggering RA flares, but without demonstrated causality, it's difficult to be certain. Large, controlled studies would be necessary to prove this and the data is not currently available.

A Word From Verywell

When thinking about vaccines, it's normal to worry about how they might affect your RA or interact with your RA drugs. It's important to remember, though, that vaccines have undergone rigorous studies in many different population groups, including people who are immunocompromised.

Guidelines published by the Advisory Committee on Immunization Practices (ACIP) can help you and your healthcare provider decide which vaccines are best for you to receive and when.