Table 2

Vaccination schedule recommendations for patients with rheumatic diseases

Vaccination recommendationRecommended modification of DMARD therapy relative to vaccine timing based on guidelines and best available evidence*, as compatible with disease activity
InfluenzaYearly quadrivalent vaccination for all patients.†‡§
Patients older than 65 should receive the high-dose quadrivalent vaccine.
May consider high-dose vaccine for all immunocompromised patients.*42 44
Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥6 months) and 4 weeks before the next dose.§
MTX: consider holding for 2 weeks after vaccination.*22 23
PneumococcalRecommended for all immunosuppressed patients.†‡§
Give one dose of PCV13 followed by PPSV23 at least 8 weeks later. Give a second PPSV23 dose 5 years after the first PPSV23 dose.
Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥6 months) and 4 weeks before the next dose.§
MTX: consider holding MTX for 2 weeks after vaccination.*
Herpes zosterRecombinant zoster vaccine for adults over age 50.†¶
Use live Zoster vaccine where recombinant is not available.
Consider in all high-risk patients with rheumatic disease.†§
Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥6 months) and 4 weeks before the next dose.*
Hepatitis BAll non-immune adults at risk for HBV infection.†‡§** Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥6 months) and 4 weeks before the next dose.§
Human papilloma virusAs per general population guidelines, especially for patients with SLE.§‡ Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥6 months) and 4 weeks before the next dose.§
TetanusAs per general population and consider for all rituximab-treated patients.§ Rituximab: vaccinate before starting rituximab.§
Yellow feverAvoid for immunocompromised patients.†§ N/A, contraindicated
SARS-CoV-2All patients as per the general population.101 ACR guidance summary101:
Rituximab: as long as possible after the last dose, 2–4 weeks before the next dose.
MTX: hold for 1 week after each mRNA dose; hold for 2 weeks after single-dose vaccine.
Mycophenolate mofetil and JAK inhibitors: hold for 1 week after each vaccine dose.
Abatacept subcutaneous: hold 1 week before and 1 week after the first vaccine dose, no interruption for the second vaccine dose.
Abatacept intravenous: time the first vaccine dose 4 weeks after abatacept and postpone next infusion by 1 week; no adjustment for the second vaccine dose
Cyclophosphamide: time cyclophosphamide 1 week after each vaccine dose.
TNF, IL-6R, IL-1, IL-17, IL-12/23, IL-23, oral calcineurin inhibitors, belimumab††, azathioprine, sulfasalazine, leflunomide, hydroxychloroquine, apremilast, intravenous immune globulin (IVIG) and glucocorticoids <20 mg/day††: no modification.
  • *Authors’ recommendations based on best available evidence.

  • †2021 Advisory Committee on Immunisation Practices recommendations.12

  • ‡2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis.40

  • §2019 European League Against Rheumatism recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases.41

  • ¶Per CDC guidelines, adults with immunocompromising conditions were not included in initial clinical trials and therefore no recommendations regarding vaccination age for this population was made. However, this may change in the future.

  • **Risk factors include: persons at risk through sexual exposure (sex partners of hepatitis B surface antigen positive persons, sexually active persons not in a long-term monogamous relationship, persons seeking evaluation or treatment for a sexually transmitted disease, men who have sex with men), persons with a history of current or recent injection drug use, persons at risk for infection by percutaneous or mucosal exposure to blood (household contact or sexual partner who is hepatitis B surface antigen positive, resident or staff of a facility for the developmentally disabled, healthcare or public safety workers with anticipated risk for exposure to body fluids, patients with end-stage renal disease, persons with diabetes mellitus aged <60 or those over age 60 at the discretion of the treating physicians), travellers to endemic areas, patients with chronic liver disease or hepatitis C infection, incarcerated persons and patients with HIV.

  • ††Data published since guideline development suggests that lower doses of prednisone and belimumab may adversely impact the SARS-CoV-2 mRNA vaccine immunogenicity.84

  • ACR, American College of Rheumatology; CDC, Center for Disease Control; DMARD, disease-modifying antirheumatic drug; IL, interleukin; JAK, Janus kinase; MTX, methotrexate; PCV13, pneumococcal conjugate vaccine 13-valent; PPSV23, pneumococcal polysaccharide vaccine 23-valent; SLE, systemic lupus erythematosus; TNF, tumour necrosis factor.