Vaccinations and Rheumatoid Arthritis

When you have rheumatoid arthritis (RA), you may worry about getting vaccinations. It's natural to wonder whether it's safe—after all, your disease involves a malfunctioning immune system, you may take drugs that alter your immune function, and vaccines work by activating your immune system.

So should you get vaccinated? The answer, in many cases, is yes. Still, you should be aware of a few precautions regarding certain vaccines.

Benefits of Vaccination

Because of your RA and the immunosuppressive medications that treat it, you may be extra susceptible to preventable diseases like influenza, shingles, pneumonia, and COVID-19. Studies show the risk may be as much as double that of someone your age without RA.

What's more, you're also more likely to develop:

• Severe infections, which can be fatal
• Complications, which can also be fatal
• Illness-related flares of RA symptoms

By keeping you from getting sick, vaccines can protect you from all these dangers.

Types of Vaccines

Vaccines expose your body to an infectious organism (pathogen), or to a component of the infectious organism, so your body can develop an immune response to it. That protects you from getting sick if you're exposed to the same organism later.

However, there are various types of vaccines which are made in different ways. When you have RA, the type of vaccine you get matters.

Live Attenuated Vaccines

Live attenuated vaccines contain live pathogens that have been weakened so they don't normally make a person sick. However, they generally aren't recommended for people with weakened immune systems, such as people receiving RA treatment. In that group, the vaccines can cause an infection, remain in your body, and emerge later to make you sick again.

However, even some vaccines of this type are safe for people on small doses of immunosuppressant drugs. However, even if you are on a small dose, talk to your physician before taking a live attenuated vaccine, as the benefits may not outweigh the potential risks.

Examples of live attenuated vaccines include:

• Measles, mumps, and rubella (MMR)
• Yellow fever
• Rotavirus
• Herpes zoster virus (shingles)
• Intranasal (nose spray) influenza

Research suggests the live-virus herpes zoster vaccine (Zostavax) is safe and effective in people with RA. In at least one study, however, a few participants had flares after being vaccinated, and the vaccine appeared less effective in people with RA than those with osteoarthritis. Another effective herpes zoster vaccine that doesn't contain live virus (Shingrix) is available, so that may be a better option.

Your doctor can guide you as to what vaccines are safe for you based on your medications, dosages, and complete medical history.

Safe Vaccine Types

Other types of vaccines don't contain a live virus and therefore can't cause an infection. These are considered safe with RA and other autoimmune diseases, even if you're on immunosuppressant medications:

• Inactivated vaccines: These contain killed pathogens and include 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 herpes zoster, diphtheria, hepatitis B, human papillomavirus (HPV), pneumococcal and meningococcal disease, and pertussis (whooping cough).
• Toxoid vaccines: These use a small, safe amount of a toxin from a pathogen, such as diphtheria and tetanus.

COVID-19 and New Vaccine Types

Several COVID-19 vaccines—some on the market and some still in development—are newer types of vaccines.

• Messenger RNA (mRNA) vaccines: These include a harmless protein that's unique to the virus and include the Moderna Pfizer-BioNTech vaccines.
• Viral vector vaccines: These contain a protein from the virus attached to another harmless virus (such as a cold virus). Examples are the Oxford-AstraZeneca, Johnson & Johnson, and CanSino Biologics vaccines.

Other COVID-19 vaccines in the works are inactivated and recombinant types. Thus far, there's no reason to believe any of the approved vaccines pose a threat to people with compromised immune systems, and the benefits of the vaccine are believed to outweigh the risks.

Vaccine Concerns

To make sure that vaccines are safe and produce the desired immune response for people with RA, two important considerations are timing and which medications the person is taking.

Timing

The best time for people with RA to receive vaccinations depends on their level of disease activity and what treatments they're receiving at the time. Vaccination is generally most effective when you're in remission, meaning you're not in an active flare or getting the more extensive treatment used to manage flares, such as systemic corticosteroids.

For example, if you are being treated with high-dose prednisone or immunosuppressants, vaccination might not produce a strong immune response, leaving you unprotected. If you are being treated with low-dose prednisone, though, you can still generate good protection from vaccination.

Vaccines and DMARDs

When it comes to the live attenuated vaccines that could cause infection in someone with a weakened immune system, the medications that raise concerns are classified as disease-modifying anti-rheumatic drugs (DMARDs). These include immunosuppressants and biologic drugs, such as:

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

These RA medications make it more likely that a live attenuated vaccine will make you sick, and they can also make vaccines less effective.

For example, in people taking methotrexate, it is recommended that you skip at least one dose and no more than two doses after vaccination.

However, 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.

Decisions as to whether you should get a live attenuated vaccine or take a break from medications in order to receive vaccines are important ones. Only you and your doctor, looking at the specifics of your health and the situation, can decide what's right for you.

Vaccine Recommendations for RA

Current guidelines on vaccinations for adults with autoimmune rheumatic diseases, including RA, offer the following precautions:

• Get up to date on vaccines before starting DMARDs whenever possible.
• Avoid vaccinations during flares.
• Live attenuated vaccines may be considered with caution.
• If you took biologics during the second half of pregnancy, your baby shouldn't get live attenuated vaccines until they're 6 months old.
• People in your household shouldn't receive the oral polio vaccine but should receive other vaccines according to the recommended schedule.

The vaccine recommendations for people with RA are summarized in the following table. Passive immunization involves receiving antibodies from a donor to protect against the condition, rather than getting the vaccine.

A Word From Verywell

When thinking about vaccines, it's normal to worry about how they'll interact with your RA and medications. Remember, though, that there's a lot of misinformation out there and that these vaccines have undergone rigorous study. Published guidelines, which are based on that research, can help you and your doctor come to the best decisions for you when it comes to which vaccinations and types to consider and avoid.