Vaccinations when taking DMARDs or Biologics Print Page
Vaccine |
Type |
Frequency |
On MTX/LEF |
On Biologic / JAKi |
|
Routine Vaccines |
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Influenzaa |
Fluviral, Agriflu, Fluzone |
Annually |
OKa |
OK1 |
|
Fluzone High-Dose |
Preferred for ≥65y, |
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FluMist (LIVE) (0.1mL each |
Not recommended |
Not recommended |
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Pneumococcalb, c Patient/Provider Vaccine Selection Decision Aid (pneumonia) |
Prevnar 20 (conjugated) (0.5mL |
● ≥18y, once |
OK |
OK1 |
|
Prevnar 13 (conjugated) (0.5mL Pneumovax (PPV-23) |
● Once
● Give ≥8 weeks later |
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Pneumovax only (PPV-23) |
Booster ≥5 years later at age |
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Tetanus |
Tdap (Adacel, Boostrix) (0.5mL |
Once as adult (pertussis) |
OK |
OK1 |
|
Td (0.5mL IM) |
Every 10 years |
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Herpes Zoster (shingles) |
Shingrix (0.5mL IM) |
● 0, 2-6 months |
Age >50 ±history of |
OK |
OK |
Prior to JAKi therapy at any |
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Childhood Vaccinations (must |
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MMRd (measles, mumps, rubella) |
MMR-II or Priorix (LIVE) 0.5mL |
If |
Use with caution2 |
Generally contraindicated2-4 |
|
HPV |
Gardasil |
Between 9-26y, if at risk |
OK |
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Varicellad (chicken pox) |
Varilrix or Varivax III (LIVE) |
Check titre/history of Age |
Use with caution2 |
Generally contraindicated2-4 |
|
Meningococcal (meningitis) |
MEN-C-ACYW-135 (quadravalent conjugate) |
If <25y, no dose recorded |
OK |
OK1 |
|
Vaccines for High Risk Groups5 |
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Hepatitis A / Hepatitis B |
Twinrix (HAV+HBV) (1mL IM) Recombivax, Engerix-B (HBV |
0, 6-36months 0, 1, 6months |
OK |
OK1 |
|
Meningococcal |
MEN-C-ACYW-135 (quadravalent conjugate) |
Travel or At Risk 0, 8wks; booster every 5 years |
OK |
OK1 |
|
Cholera |
Dukoral (oral) |
Travel |
Unnecessary – give antibiotics for treatment PRN |
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Typhoid |
Typherix or Typhim Vi |
Travel |
OK |
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Vivotif (LIVE) |
Generally contraindicated2-4 |
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Japanese encephalitis |
Ixiaro |
Travel |
OK |
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Yellow Feverd |
YF-Vax (LIVE) |
Travel |
Absolutely contraindicated4 Provide waiver or delay travel |
a Evidence supports withholding MTX (only) for 1 week post-influenza vaccination to optimize immunogenicity if the patient’s disease activity allows and using shared decision making. Guidelines recommend continuing other DMARDs around the time of any non-live vaccination, except RTX (delay dose ≥2-4 weeks).
b Prevnar-20 is a new conjugated vaccine that will replace Prevnar-13 and Pneumovax-23; however, it is not yet covered by AB Health (but may be covered by private insurance).
- See flow diagram to determine which pneumococcal vaccine(s) is/are recommended.
- Note: if Prevnar-20 is not covered and a patient has received Pneumovax-23 previously, administer Prevnar-13 at least 1 year later, followed by a Pneumovax-23 booster 5 years after the first dose.
c Alberta Health covers Prevnar-13 and Pneumovax-23 for patients with inflammatory arthritis taking therapy/therapies beyond HCQ and/or SSZ. Pneumovax-23 is available at community pharmacies, however, publicly funded Prevnar-13 is only available at community health centres.
d An injected live vaccine (MMR, varicella, zoster, yellow fever) can be given simultaneously (on the SAME day) with a TB skin test, BUT if provided >1 day prior, you must wait 4-6 weeks before placing the skin test, as there is a risk of a false-negative skin test in a person who has a TB infection. Inactive vaccines can be given on the same day or any time after a TB skin test.
1 Ideally, provide ≥14 days before biologic initiation/next dose
2 Administer live vaccines ≥4 weeks before DMARD initiation or at least 1 month after stopping csDMARD, ≥1 week after stopping tsDMARD, and ≥1 dosing interval for bDMARD and IV cyclophosphamide therapies.
3 To ensure minimal immunosuppression (reduce risk of infection) and optimal vaccine response: recommend waiting >3 half-lives after stopping biologics to give live vaccines. To ensure safety, guidelines recommend waiting ≥6mo after the last dose of RTX.
Mean Half-life (d) | 2 Half-lives (d) | 5 Half-lives (d) | |
Adalimumab | 14 | 28 | 70 |
Certolizumab | 14 | 28 | 70 |
Etanercept | 4.3 | 8.6 | 22 |
Golimumab | 12 | 24 | 60 |
Infliximab | 8-10 | 16-20 | 40-50 |
Abatacept | 13 | 26 | 65 |
Rituximab | 21 | 42 | 105 |
Sarilumab | 8-10 | 16-20 | 40-50 |
Tocilizumab | 13 | 26 | 65 |
4 Under compelling circumstances may be considered; consultation with an infectious diseases physician is recommended.
5 High-Risk Groups:
- Hepatitis A: travel to, immigrants from, or residence in endemic countries of HAV; occupational exposure (i.e. health care professionals); infected family member or contacts; illicit drug users; men who have sex with men; chronic liver disease.
- Hepatitis B: residents, immigrants, travelers, or close contact with individuals from HBV endemic areas; persons with lifestyle risks: illicit drug use (injectable or non-injectable), oral sex, men who have sex with men, other high risk sexual practices; chronic liver disease; chronic kidney disease; occupational exposure (i.e. health care professionals); frequent blood transfusions.
- HPV: previous STI, number of partners, inconsistent condom use, men who have sex with men (not covered by public health)
- Meningococcal: travellers to sub-Saharan Africa, Mecca, Saudi Arabia; laboratory or military personnel; close contact of a case of invasive meningococcal disease or outbreak control, high risk medical conditions.