Background & Objectives
This guideline provides evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). RMDs and the immunosuppressive medications used to treat them place patients at higher risk of vaccine-preventable infections and of more serious complications of infection. However, the immunogenicity and safety of vaccines may differ in patients with RMDs than in members of the general population, and patients with RMDs may benefit from modified vaccine indications and/or adjustments to vaccination or medication schedules.
Methods
This guideline follows the ACR policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation.
The target audience is limited to rheumatology providers in the U.S. because the epidemiology of vaccine-preventable infections and the availability of specific vaccines vary across the globe.
Note: Vaccinations against COVID-19 are not included in this guideline because, given the fast-changing nature of the pandemic and the COVID-19-related literature, concerns arose that recommendations would be obsolete well before guideline publication. COVID-19 vaccinations will be incorporated into a future guideline update once the pertinent literature has stabilized.
Results
This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low-quality supporting evidence.
Influenza vaccination
For patients with rheumatic and musculoskeletal diseases who are age 65 or older, as well as those older than 18 but younger than 65 who are taking immunosuppressive medications, high-dose or adjuvanted influenza vaccination is conditionally recommended over regular-dose influenza vaccination. Any influenza vaccine is preferred over no influenza vaccine, and vaccination “today” is preferred over delay. Therefore, if high-dose or adjuvanted influenza vaccine is not available in the clinic during a patient visit when influenza vaccination is indicated, then standard-dose influenza vaccine should be administered.
Pneumococcal & VZV vaccinations
For patients with RMD age younger than 65 who are taking immunosuppressive medication, pneumococcal vaccination is strongly recommended. For patients with RMD older than 18 who are taking immunosuppressive medication, administering the recombinant varicella-zoster virus (VZV) vaccine is strongly recommended.
Conclusion
Application of these recommendations should consider patients’ individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held. Shared decision making with patients is encouraged in clinical settings.
This guideline addresses vaccination strategies across the entire adult and pediatric RMD spectrum. An underlying principle in this guideline is that patients should be vaccinated and that missed vaccination opportunities should be avoided or minimized. This is particularly true of influenza vaccination, which is administered seasonally and is recommended for RMD patients even if their disease activity is high, they are taking high-dose glucocorticoids and/or are taking rituximab.
For full study details, including source material, refer to the full guideline.
Excerpted and adapted from:
Bass AR, Chakravarty E, Akl EA, et al. 2022 American College of Rheumatology guideline for vaccinations in patients with rheumatic and musculoskeletal diseases. Arthritis Rheumatol. 2023 Mar;75(3).
