ACR Releases Guidelines for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases

The American College of Rheumatology (ACR) released guidelines for vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). The full report has been published in Arthritis & Rheumatology. 

Overall, the guidelines include recommendations on holding immunosuppressive medications and/or delaying vaccination to maximize vaccine immunogenicity and efficacy, as well as safe approaches while using the live attenuated vaccines. In addition, expanded indications for some vaccines in patients with RMDs have also been noted.

The population, intervention, comparison, and outcomes (PICO) format was used to formulate clinical questions. Systematic literature reviews were conducted to address each PICO question, and the quality of evidence was graded as high, moderate, low, or very low. Using the Grading of Recommendations Assessment and Development and Evaluation (GRADE) methodology and adhering to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria, recommendations were developed based on the best available evidence. An expert voting panel reviewed the evidence and formulated recommendations. A virtual patient panel, including 9 adult and pediatric patients with RMDs, provided patient perspectives and preferences for the voting panel to consider. Consensus on both the strong and conditional recommendations was achieved by a 70% level of agreement.

The following guiding principles were implemented in the current guidelines:

1. Patients must be administered the indicated vaccines whenever possible.
2. The ACR guidelines complement recommendations by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP).
3. Disease, disease activity, and risk for vaccine-preventable infection must be considered when deciding to hold a medication before or after vaccination.
4. Shared decision-making with patients is an essential part of any vaccine approach.

The majority of the recommendations were noted to be conditional and were supported by very low-quality evidence.

Expanded Vaccination Indications for Patients With RMDs Receiving Immunosuppressive Medications

Influenza Vaccination

• Administering high-dose or adjuvanted influenza vaccines is conditionally recommended over regular-dose influenza vaccines for patients with RMDs aged 65 years and older, and those younger than 18 years and those younger than 65 years receiving treatment with immunosuppressive medications.

Pneumococcal Vaccination

• The pneumococcal vaccine is strongly recommended for patients with RMDs younger than 65 years and receiving treatment with immunosuppressive medications.

Recombinant Varicella-Zoster Virus (VZV) Vaccination

• The recombinant VZV vaccine is strongly recommended for patients with RMDs who are older than 18 years and receiving treatment with immunosuppressive medications.

Human Papillomavirus (HPV) Vaccination

• Vaccination against HPV is conditionally recommended for patients with RMDs who are aged between 26 and 45 years, receiving treatment with immunosuppressive medications, and have never previously received the vaccine.

The ACR also noted whether holding immunosuppressive medications while receiving a nonlive attenuated vaccine will maximize vaccine immunogenicity, though holding medications may cause disease flares.

Methotrexate

• Holding methotrexate for 2 weeks after receiving an influenza vaccine is conditionally recommended for patients with RMDs, based on disease activity.

Medications Other Than Methotrexate

• Around the time of influenza vaccination, patients with RMDs are conditionally recommended to continue receiving immunosuppressive medications other than methotrexate.
• Continuing immunosuppressive medications around the time of other (non-influenza) nonlive attenuated immunizations is conditionally recommended for patients with RMDs.

Vaccines to Patients Receiving Rituximab

• The ACR conditionally recommended that patients with RMDs receiving treatment with rituximab receive influenza vaccination on schedule rather than waiting until their next dose of rituximab.
• Rituximab has been conditionally recommended to be delayed for 2 weeks following vaccination for patients with RMDs, as well as to postpone nonlive attenuated vaccines (except influenza vaccination) until the next time rituximab is administered.

Nonlive Attenuated Vaccines for Patients Receiving Glucocorticoids

• Any nonlive attenuated vaccines are strongly recommended for patients with RMDs who receive the equivalent of 10 mg of prednisone daily.
• Administering any nonlive attenuated vaccines to patients with RMDs who receive the equivalent of prednisone of greater than 10 mg daily but less than 20 mg daily has been conditionally recommended.
• Influenza vaccination is conditionally recommended for patients with RMDs receiving 20 mg or more of prednisone daily.
• Delaying nonlive attenuated vaccines, other than the influenza vaccine, until glucocorticoids are tapered to the equivalent of prednisone less than 20 mg daily is conditionally recommended for patients with RMDs receiving the equivalent of prednisone of at least 20 mg daily.

Delaying Vaccination  

• Regardless of the severity of disease activity, administering nonlive attenuated vaccines is conditionally recommended for patients with RMDs to increase vaccine immunogenicity.

Managing Immunosuppressive Treatment During Live Attenuated Vaccination

• The ACR has conditionally recommended to delay live attenuated vaccines in patients with RMDs receiving treatment with immunosuppressive medications.
• The ACR also conditionally recommended to delay using immunosuppressive medications for an appropriate amount of time before and 4 weeks after receiving a live attenuated vaccine.

Administering Rotavirus Vaccine to Infants Receiving Biologic Disease-Modifying Antirheumatic Drugs (DMARDs) In Utero

• The ACR has conditionally recommended the administration of live attenuated rotavirus vaccination within the first 6 months of life to newborns and infants who had second- and/or third-trimester prenatal exposure to tumor necrosis factor inhibitors (TNFi).
• It has been conditionally recommended to delay live attenuated rotavirus vaccination until after 6 months for newborns and infants who had second- and/or third-trimester prenatal exposure to rituximab.

Administrating Multiple Vaccines to Patients With RMDs on the Same Day

• The ACR has conditionally recommended to administer as many vaccines as feasible on the same day rather than 1 vaccine at a time.

Overall, the authors of the paper concluded, “Application of these recommendations should consider patients’ individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.”