Ariel L. Clark, PharmD
Vaccinations are widely viewed as one of the greatest success stories in the history of public health. From development of the first smallpox vaccine to the continual research into a vaccine for various cancers and immunodeficiencies, they continue to protect people across the globe. Unfortunately, those with rheumatic and musculoskeletal disorders (RMDs) often may not achieve the same level of protection from infection as those without. The drugs that are used to treat RMDs put patients at an inherently higher risk for infection from diseases.
In developing new vaccination guidelines for adults and children with RMDs, the American College of Rheumatology (ACR) published recommendations in 2022 for influenza vaccination, pneumococcal vaccination, HPV vaccinations, and more.
In the new guidelines, ACR recommends that patients with RMDs receive a quadrivalent influenza vaccine over the standard dose.
However, this recommendation should not prevent patients from getting vaccinated. If pharmacists and other health care providers do not have the quadrivalent in stock, patients should be advised to obtain any flu shot over no flu shot at all.
Vaccination against pneumococcal infection is strongly recommended by ACR. For those taking immunocompromising medications who are under the age of 65, CDC recommends vaccination with pneumococcal conjugate vaccine (PCV13), followed by polysaccharide vaccine (PPSV23).
Adults over the age of 65 with RMD who do not know or who do not have access to their vaccine records should receive booster doses. CDC currently recommends a pneumococcal conjugate vaccine (either 13- or 15-variant) followed by a dose of polysaccharide vaccine at least 2 months later.
Varicella zoster vaccination
Patients with RMDs are at higher risk for herpes zoster than older adults, according to the guideline authors. Vaccination has been proven effective in patients who have undergone transplants, including those of kidneys and stem cells; it is therefore strongly recommended. However, providers should discuss the possibility of mild disease flares with patients who are thinking about getting vaccinated.
For patients taking immunocompromising medications, there may be an increased risk for uterine cancer development, so HPV vaccination is universally recommended in this update.
The guideline authors advise providers to refrain from giving live vaccines until patients have ceased using their medications for an “appropriate period before and 4 weeks after live attenuated vaccinations.” The appropriate period before depends on the agent being used by the patient, and providers should review the guideline for each patient, particularly for infants who were exposed to RMD drugs while in utero.
Treatment drugs and whether or not to hold them
Methotrexate is one of the most commonly used drugs for RMDs. Other medications can include glucocorticoids and injectable biologic agents like rituximab.
Methotrexate can be continued without interruption for vaccinations other than influenza. For flu vaccines, the ACR guidelines recommend providers hold methotrexate for up to 2 weeks due to the risk of reduced flu vaccine effectiveness. However, vaccination should not be delayed and providers are encouraged to use shared decision-making based on disease activity.
According to this update, rituximab injection may be given on schedule when the patient receives a flu vaccine. But providers should delay other vaccines, including pneumococcal vaccines, until the next dose is due, and they should have the patient delay the dose after the shot by 2 weeks.
Glucocorticoid schedule interruption is based on what dosage the patient is taking. Providers should consult the ACR update and assess their patient’s individual case.
Providers are encouraged to listen to patient concerns, particularly about disease flare-ups. Although studies have not shown an increased rate of flare-ups, shared decision-making can help ease patient apprehension.
Protecting patients with RMDs via vaccinations is critically important, both for their health and for global health. This guideline update may better aid providers in understanding when and how to follow traditional vaccine schedules and when to deviate from them in order to best protect their patients. ■