ACR Releases New Vaccination Guideline

Non-Live Vaccines

With a few exceptions, the guideline conditionally recommends against holding immunosuppressive medications before or after non-live vaccinations. Dr. Bass points out that much of the data the guideline developers analyzed were indirect, and they leaned toward not holding medicines in the absence of clearer evidence.

An exception: The guideline contains a conditional recommendation to hold methotrexate for two weeks after influenza vaccination, if disease activity allows. This recommendation is based on two randomized controlled trials showing the negative impact of methotrexate on immunogenicity postinfluenza vaccination. This recommendation does not apply to other non-live vaccines.

Another exception: rituximab. For patients taking rituximab, non-live vaccinations should ideally be timed to be given at the time of the next scheduled rituximab dose, holding for at least two weeks thereafter. Dr. Bass points out that the negative impact of rituximab on vaccine immunogenicity became more evident from research related to COVID-19. However, because of the seasonal nature of influenza, a conditional recommendation is to give patients taking rituximab the influenza vaccine on schedule.

Dr. Bass

One other exception: glucocorticoids. The guideline conditionally recommends non-live vaccinations be deferred if the dosage is 20 mg daily or more. However, it’s also conditionally recommended that such patients receive the influenza vaccine on schedule.

Expanded Indications

The guideline also describes multiple scenarios for expanded vaccine indications. These include high-dose or adjuvanted influenza vaccine in patients with rheumatic diseases taking immunosuppressants. No important safety signals have been found for high-dose or adjuvanted vaccines, “so we felt that it was a good way to make sure patients get adequate responses to influenza vaccination even if they’re on immunosuppressive medication,” says Dr. Bass.

The guideline also spells out recommendations already made by the Centers for Disease Control and Prevention (CDC) for patients taking immunosuppressants: the pneumococcal vaccine, a strong recommendation for those younger than 65; the varicella zoster vaccine (VZV), a strong recommendation for those older than 18; and the human papillomavirus vaccine, a conditional recommendation for those between 25 and 45.³

“Our recommendations are really no different from those of the CDC for immunosuppressed persons who are under the general population age cutoff, so it’s really more a matter of emphasis,” says Dr. Bass.

Live Vaccines

Ideally live vaccines can be deferred while patients are on immunosuppressants, but this is not always possible in patients requiring long-term therapy. The guideline also contains recommendations for holding immunosuppressants before and after vaccination with live vaccines, which harbor the risk of vaccine-induced illness. For example, methotrexate may be held for four weeks before and four weeks after live vaccination.