Vaccination Guidelines for Rheumatic, Musculoskeletal Diseases

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A literature review team provided an evidence-based recommendations on vaccinations in children and adults with rheumatic and musculoskeletal diseases.

The American College of Rheumatology (ACR) has distributed a summary of their evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). These recommendations are included in a full manuscript, which will be submitted for publication in the journals Arthritis & Rheumatology and Arthritis Care & Research.

The updated 2022 guideline follows the ACR guideline development process, as well as the ACR policy guiding management of conflicts of interest and disclosures, including the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The guideline adheres to the Appraisal of Guidelines for Research & Evaluations (AGREE) criteria.

Clinical population, intervention, comparator, and outcomes (PICO) questions were drafted by a core leadership team that comprised pediatric and adult rheumatologists. A literature review team was responsible for performing a systematic literature review for the PICO questions, grading the quality of evidence, and producing the evidence report. Following this, the evidence was reviewed and recommendations were formulated by an expert voting panel that comprised pediatric and adult rheumatology providers, infectious disease specialists, and patient representatives. To obtain consensus, agreement of at least 70% on both the strength and the direction of each recommendation was required.

The expanded indications for specific vaccines in patients with RMDs receiving immunosuppression include the following:

  • The administration of high-dose or adjuvanted influenza vaccination is conditionally recommended over the administration of regular-dose influenza vaccination in patients aged at least 65 years, as well as those aged between 18 years and 65 years who are receiving immunosuppressive medication;
  • The administration of pneumococcal vaccination is strongly recommended in patients aged older than 65 years who are receiving immunosuppressive medication;
  • The administration of recombinant zoster vaccine is strongly recommended in patients aged younger than 18 years who receive immunosuppressive medication; and
  • Vaccination against human papillomavirus is conditionally recommended Patients aged between 26 years and 45 years who are receiving immunosuppressive medication and who have not previously been vaccinated.

Management of medication at the time of administration of non-live attenuated vaccine in patients with RMDs includes instructions on the following:

  • Holding methotrexate (MTX) for 2 weeks after influenza vaccination and continuing MTX after administering other non-live attenuated vaccinations;
  • Continuing rituximab (RTX) after influenza vaccination, and timing administration of non-live attenuated vaccinations for when the next RTX dose is due, then holding RTX for at least 2 weeks after vaccination;
  • Continuing immunosuppressive medications others than MTX and RTX after administering influenza vaccination and other non-live attenuated vaccinations.

In patients with RMDs who are receiving glucocorticoids, influenza vaccination can be administered in those receiving prednisone 10 mg/day or less, prednisone between 10 mg and 20 mg/day, and prednisone at least 20 my/day. In patients who are receiving glucocorticoids, other non-live attenuated vaccinations can be administered to those taking prednisone 10 mg/day or less, as well as prednisone between 10 mg and 20 mg/day, but should be deferred in those receiving prednisone at least20 mg/day.

Other recommendations in the revised ACR guideline include the following:

  • Administering multiple vaccinations on the same day, rather than administering each individual vaccination on a different day, is conditionally recommended;
  • Administering non-live attenuated vaccinations is conditionally recommended regardless of their disease activity;
  • Deferring live-attenuated vaccines is conditionally recommended in patients with RMD who are receiving immunosuppressive medication; and
  • Holding immunosuppressive medication for an appropriate period before and for 4 weeks after receiving live-attenuated virus vaccination is conditionally recommended.

According to the authors, “Application of these recommendations should take into consideration 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.”


American College of Rheumatology. 2022 American College of Rheumatology (ACR) guideline for vaccinations in patients with rheumatic and musculoskeletal diseases: guideline summary. Updated July 11, 2022. Accessed August 10, 2022.