Vaccine guidelines for:
- >18 yo-<65 yo with rheumatic or musculoskeletal disorders on immunosuppression AND
- Adults (≥65 yo) with rheumatic and musculoskeletal disorders with or without immunosuppression
- Pneumococcal conjugate vaccine (PCV15) followed 12 months later by polysaccharide vaccine (PPSV23) OR
- Single-dose PCV20
Recommended
- Two vaccination series
- Time the 2nd dose 1-2 months from the first dose, as per CDC recommendation
Recommended
- High dose or adjuvanted preferred over regular dose
- If on methotrexate, recommend holding for 2 weeks after vaccination
Recommended
- Age ≤45 yo and not previously vaccinated in childhood
- One updated Pfizer-BioNTech or Moderna COVID-19 vaccine plus one additional dose of updated vaccine 2 or more months after 1st updated vaccine (4 or more months if not moderate to severely immunocompromised)
Includes: Intranasal influenza, MMR, rotavirus, typhoid, varicella, yellow fever, zoster
- HOLD immunosuppressive medication (view list of immunosuppression medications) prior to and after vaccination in collaboration with rheumatologist
- Immunosuppressive medication management at the time of live-attenuated virus vaccine administration
- For rheumatology patients who are on immunosuppressive medication, deferring live-attenuated vaccines is conditionally recommended.
- For rheumatology patients, holding immunosuppressive medication for an appropriate period before (see table below) and 4 weeks after live-attenuated virus vaccination is conditionally recommended.
| Immunosuppressive medication | Hold BEFORE live-attenuated virus vaccine administration | Hold AFTER live-attenuated virus vaccine administration |
|---|---|---|
| Glucocorticoidsa | 4 weeks | 4 weeks |
| Methotrexate, azathioprineb | 4 weeks | 4 weeks |
| Leflunomide, mycophenolate mofetil, calcineurin inhibitors, oral cyclophosphamide | 4 weeks | 4 weeks |
| JAK inhibitors | 1 week | 4 weeks |
| TNF, IL17, IL12/23, IL23, BAFF/BLyS inhibitors | 1 dosing intervalc | 4 weeks |
| IL-6 pathway inhibitors | 1 dosing intervald | 4 weeks |
| IL-1 inhibitors Anakinra Rilonacept Canakinumab |
1 dosing intervald 1 dosing intervald 1 dosing intervald |
4 weeks |
| Abatacept | 1 dosing intervalc | 4 weeks |
| Anifrolumab | 1 dosing intervalc | 4 weeks |
| Cyclophosphamide IV | 1 dosing intervalc | 4 weeks |
| Rituximab | 6 months | 4 weeks |
| IVIGe 300-400 mg/kg 1 gm/kg 2 gm/kg |
8 months 10 months 11 months |
4 weeks 4 weeks 4 weeks |
a For patients taking the equivalent of prednisone <20 mg/day or <2 mg/kg/day for patients weighing <10 kg, or alternate-day glucocorticoid therapy (i.e., “low level immunosuppression” (14, 68)), these low doses can be continued if vaccination is critical and the risk of a disease flare or adrenal insufficiency off glucocorticoids is high.
b For patients taking methotrexate ≤0.4 mg/kg/week or azathioprine ≤3 mg/kg/day (“low level” immunosuppression” (14, 68)), hold times can be shortened if vaccination is critical and the risk of a disease flare off immunosuppression is high.
c For medications with more than one FDA-approved dosing interval, the longest interval should be chosen (e.g., hold subcutaneous adalimumab for 2 weeks, although it can be dosed every 1 or every 2 weeks).
d In children with autoinflammatory disorders or systemic juvenile idiopathic arthritis in whom the risk of disease flare if biologic DMARDs are held is very high, shorter hold times can be considered if live-attenuated vaccination is critical.
e The recommendation to hold IVIG prior to vaccination is designed to enhance vaccine efficacy, not safety. In some situations, such as during a measles outbreak, earlier vaccination would be preferred over delay.
Special Considerations
- For patients taking the equivalent of prednisone ≥20 mg/d, defer vaccinations (except influenza) until tapered <20 mg/d
- No contraindications to giving multiple vaccinations to patients on same day
- Medication management at the time of non-live attenuated vaccine administration (see below)
Influenza vaccination
- Hold methotrexate for 2 weeks after vaccination
- Hold only if disease activity allows.
Non-rheumatology providers, e.g., general pediatricians and internists, are encouraged to give the influenza vaccination and then consult with the patient’s rheumatology provider about holding methotrexate to avoid a missed vaccination opportunity.
Other non-live attenuated vaccinations
- Continue methotrexate
Influenza vaccination
- Continue rituximab
- Give influenza vaccination on schedule. Delay any subsequent rituximab dosing for at least 2 weeks after influenza vaccination if disease activity allows.
Other non-live attenuated vaccinations
- Time vaccination for when the next rituximab dose is due, and then hold rituximab for at least 2 weeks after vaccination
For immunosuppressive medications other than methotrexate and rituximab:
Influenza vaccination
- Continue immunosuppressive medication
Other non-live attenuated vaccinations
- Continue immunosuppressive medication
Recommendations above are conditional