ACR Releases 2022 Vaccination Guideline Summary for Patients With RMDs

The American College of Rheumatology (ACR) released a summary of the updated guidelines surrounding vaccinations in both adult and pediatric patients with rheumatic and musculoskeletal diseases (RMDs).

Specifically, the 3-page summary includes expanded indications for certain vaccines and safe approaches for using live attenuated vaccines among patients taking immunosuppressants, as well as medication management at the time of vaccination.

“Patients worry about the safety of vaccines and the potential for inducing a disease flare. Providers are concerned whether rheumatic diseases and the medications used to treat them could blunt the effectiveness of vaccines,” Anne R. Bass, MD, professor of clinical medicine, Hospital for Special Surgery and Weill Cornell Medicine in New York, said in a statement. “They also want to know whether certain vaccines should be given to protect rheumatology patients who are outside the age range for which they are typically recommended. This guideline was designed to address these issues.”

However, it is noted in the summary that these recommendations are supported by overall low-quality evidence, and that most of the suggestions are conditional considering that vaccine efficacy and safety may vary between patients with RMDs and the general population.

“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,” the guideline summary read. “Shared decision-making with patients is encouraged in clinical settings.”

Expanded indications for specific vaccines in patients with RMDs taking immunosuppressants included 4 major recommendations:

1. For both older adults with RMDs ≥ 65 years and patients aged between 18 and 65 years with RMDs taking immunosuppressive medications, the ACR recommends administering a high-dose or adjuvanted influenza vaccine instead of a regular-dose influenza vaccine.
2. For patients taking an immunosuppressive medication, the ACR strongly recommends pneumococcal vaccination for patients younger than 65 years
3. For patients taking an immunosuppressive medication who are older than 18 years, ACR strongly recommends a recombinant zoster vaccine.
4. For patients between 26 and 45 years who are taking an immunosuppressive medication and are not yet vaccinated, the guideline conditionally recommends vaccination against HPV.

Regarding whether to administer multiple vaccines to a single patient with an RMD on the same day or administering one at a time, the ACR conditionally recommends administering multiple on the same day.

It is also suggested that patients with active RMD, patients taking high-dose glucocorticoids and/or patients taking rituximab still receive their seasonal influenza vaccine.

For patients who are taking rituximab, the ACR conditionally recommended that non-influenza vaccines be given at least 6 months after the last dose. In another conditional recommendation, methotrexate should be held for 2 weeks after the patient receives the influenza vaccine as long as the disease activity allows.

According to the ACR, health care providers who are not specifically rheumatologists should administer the influenza vaccine and consult with their patient’s rheumatology provider about holding methotrexate.

Regardless of disease activity, giving non–live-attenuated vaccinations to patients taking glucocorticoids is conditionally recommended.

Conditional recommendations surrounding live-attenuated vaccines include deferring such vaccines for patients taking an immunosuppressive medication, as well as holding the immunosuppressive medication for an appropriate period before—determined by a table included in the summary—and 4 weeks after vaccination.

While the recommendations surround vaccination, COVID-19 vaccines were not part of this summary.

“Some recommendations for medication holding around the time of vaccination differ from those recommended in an earlier COVID vaccine guidance document," said Bass. "This is because prior to the introduction of COVID-19 vaccines in late 2020, there was little population-level immunity to the SARS-CoV-2 virus, and maximizing vaccine efficacy was a public health imperative."

The guideline summary was approved by the ACR Board of Directors in July 2022. The included recommendations will be in a full manuscript to be submitted for publication in both Arthritis & Rheumatology and Arthritis Care and Research, which is anticipated to be published early 2023.