Vaccinations and Rheumatoid Arthritis

Vaccinations can help protect you from certain infections if you have rheumatoid arthritis (RA). Vaccinations do not worsen the condition, but some vaccines might not be effective or could cause an infection if you have RA.

With RA, you may be at increased risk of preventable infections. The condition can predispose you to infections, and the immunosuppressive medications used to manage RA can increase your risk as well. Several vaccinations are recommended for adults, and you would need to have these vaccines if you have RA. A number of vaccine recommendations for patients with RA have been put in place to help guide the process.

Types of Vaccinations

There are different types of vaccines: killed (inactivated), live attenuated (a weakened version of live virus or bacteria), or subunit. The subunit, usually a protein or a sugar molecule, may be extracted from a virus or bacteria or made in the laboratory.

Vaccines expose your body to an infectious organism, or to a component of the infectious organism. This exposure causes your body to have an immune response, which protects you from getting sick if you are exposed to the infectious organism later.

Common vaccines include:

• Attenuated vaccines: Measles, mumps, and rubella (MMR)
• Killed vaccines: Anthrax, cholera, hepatitis A, influenza injection, plague, poliomyelitis, and rabies
• Live attenuated vaccines: Tuberculosis, influenza nasal spray, smallpox, oral typhoid, herpes zoster (chickenpox), and yellow fever
• Protein subunit vaccines: Diphtheria, hepatitis B, and pertussis
• Sugar subunit vaccines: Meningococcus, pneumococcus, Haemophilus influenza B (a sugar vaccine with protein conjugate), and typhoid injection

General vaccine recommendations vary by age and region of the world and are based on the risk of exposure to an infectious organism. The anthrax vaccine is not currently available for the general population, and the smallpox vaccine has not been given since the early 1970s.

People With Rheumatic Disease Have Concerns

Because vaccines elicit an immune response, and RA is a disease that affects the immune system, some people with rheumatic diseases who take disease-modifying anti-rheumatic drugs (DMARDs) like immunosuppressant or biologic drugs may be concerned about the interaction. In addition, some people with rheumatic diseases, such as lupus, may have concerns about the safety and effectiveness of vaccines.

Should you be concerned? What are the facts?

Safety

Killed vaccines, protein, and sugar vaccines are considered safe, even for people with rheumatic disease who are treated with immunosuppressant medications.

A live vaccine can cause an infection and can also stay in the body and re-emerge in people who are being treated with immunosuppressants. However, these vaccines are recommended for people with RA, under most conditions. You and your doctor would have to decide if and when you should receive certain live vaccines.

Effectiveness

Vaccination is most effective when people with RA are doing well (not in a flare) and not on extensive treatment.

For example, if you are being treated with high-dose prednisone or immunosuppressants, you might not produce strong antibodies and can be left unprotected even after being vaccinated. If you are being treated with low-dose prednisone, you can still generate good protection with vaccination, though.

Do Vaccines Cause or Worsen Rheumatic Disease?

Vaccines are not considered a cause of rheumatic disease or a risk factor for worsening rheumatic disease.

Infections can be serious if you have RA or another autoimmune disease or if you are taking immunosuppressive therapy. If your immune system is impaired due to disease or treatment, it is generally considered safer to get a vaccine than to get an infection. A vaccine triggers a limited immune response, whereas an infection damages the body and triggers an immune response.

An infection can temporarily worsen RA and other rheumatic diseases, triggering a flare.

Bottom Line

Current guidelines regarding vaccines and adults who have autoimmune inflammatory rheumatic diseases (AIIRD):

• The vaccination status and indications for further vaccination in patients with AIIRD should be assessed yearly
• An individualized vaccination program should be made
• Vaccination in AIIRD should not take place during a flare-up
• Vaccines should be preferably administered prior to planned immunosuppression, in particular, B cell depleting therapy
• Non-live vaccines can be administered in AIIRD during the use of glucocorticoids and DMARDs
• Live-attenuated vaccines may be considered with caution with AIIRD

Specific vaccination recommendations:

• Influenza vaccination should be strongly considered for the majority of patients with AIIRD
• Pneumococcal vaccination should be strongly considered for the majority of patients with AIIRD
• Patients with AIIRD should receive tetanus toxoid vaccination in accordance with recommendations for the general population. Passive immunization should be considered for patients treated with B cell depleting therapy
• Hepatitis A and hepatitis B vaccines should be administered to AIIRD patients at risk — in specific situations, booster or passive immunization is indicated
• Herpes zoster vaccination may be considered in high-risk patients with AIIRD
• Vaccination against yellow fever should be generally avoided in patients with AIIRD
• Patients with AIIRD, in particular patients with SLE, should receive vaccinations against HPV in accordance with recommendations for the general population
• Immunocompetent household members of patients with AIIRD should be encouraged to receive vaccines according to national guidelines with the exception of the oral polio vaccine
• Live-attenuated vaccines should be avoided during the first 6 months of life in newborns of mothers treated with biologics during the second half of pregnancy