Screening/Preventive Therapy
Table 8. Use of Vaccines in Patients with Rheumatoid Arthritis
Starting or Currently Receiving DMARDs or Biologics
a
Killed vaccines
Pneumococcal
b
Influenza
(Intramuscular)
Hepatitis B
c
Before initiating therapy
DMARD
monotherapy
✔ ✔ ✔
Combination
DMARDs
✔ ✔ ✔
TNFi Biologics
✔ ✔ ✔
Non-TNF Biologics
✔ ✔ ✔
While already taking therapy
DMARD
monotherapy
✔ ✔ ✔
Combination
DMARDs
✔ ✔ ✔
TNFi Biologics
✔ ✔
✔
e
,
h
Non-TNF
Biologics
g
✔ ✔
✔
e
,
h
✔ = Recommend vaccination when indicated (based on age and risk)
Adapted from 2012 ACR RA treatment recommendations
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a
e ACR endorsed all 2012 RA treatment recommendations for vaccination with one exception
(see footnote 'h') and re-voted only for certain immunization recommendations in patients receiving
biologics. All recommendations were conditional, except for a strong recommendation (in green) to
use appropriately indicated killed/inactivated vaccines in patients with early or established RA
who are currently receiving biologics.
b
e Centers for Disease Control and Prevention also recommends a one-time pneumococcal
revaccination aer 5 years for persons with chronic conditions such as rheumatoid arthritis
(RA). e CDC recommends pneumococcal conjugate vaccine, PCV13 or Prevnar 13
®
, for all
children younger than 5 years of age, all adults 65 years or older, and persons 6 through 64 years
of age with certain medical conditions. Pneumovax
®
is a 23-valent pneumococcal polysaccharide
vaccine (PPSV23) that is currently recommended for use in all adults 65 years of age or older
and for persons who are 2 years and older and at high risk for pneumococcal disease (e.g., those
with sickle cell disease, HIV infection, or other immunocompromising conditions). PPSV23 is
also recommended for use in adults 19 through 64 years of age who smoke cigarettes or who have
asthma.
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c
If hepatitis risk factors are present (e.g., intravenous drug abuse, multiple sex partners in the previous
6 months, health care personnel).
d
e ACR conditionally recommends that in RA patients aged ≥50, the herpes zoster vaccine should
be given before the patient receives biologic therapy or tofacitinib for their RA.
e
Evidence Level was "very low" for these recommendations. Evidence level for the remaining
recommendations that were endorsed from the 2012 ACR RA treatment guideline was similar (on
a different scale).
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