Recommendations for Vaccinations in Adult Inflammatory Arthritis Patients on Immunomodulating Therapy Print Page

Vaccine

Type

Frequency

On MTX/LEF

On Biologic

Routine Vaccines

Influenzaa

Fluviral, Agriflu, Fluzone (quadrivalent, 0.5mL IM)

Annually 

OKa

OK1

Fluzone High-Dose (quadrivalent), Fluad (adjuvanted, trivalent, 0.5mL IM)

Preferred for 18+ on DMARD and all adults 65+

FluMist (LIVE) (0.1mL each nostril)

Not recommended

Not recommended

Pneumococcalb, c

(pneumonia)

NEWPrevnar 20 (conjugated) (0.5mL IM)

Once 

Age 18+ and has NOT previously received 1 dose of Prevnar-13 AND 2 doses of Pneumovax-23

OK

OK1

Age <65 when received Prevnar-13 and Pneumovax-23: eligible at 65+

Tetanus

Tdap (Adacel, Boostrix) (0.5mL IM)

Once as adult (pertussis)

OK

OK1

Td (0.5mL IM)

Every 10 years

Herpes Zoster (shingles)

Shingrix (0.5mL IM)

Once 
(2 doses, 2-6 months apart)

Age >50 ±history of shingles ≥1 year prior

OK

OK

Prior to JAKi therapy at any age 

Childhood Vaccinations (must be up-to-date)

MMRd

(measles, mumps, rubella)

MMR-II or Priorix (LIVE) 0.5mL SC

If born 1970

  no dose recorded (2 doses)

  received 1 MMR dose (check serology, provide 1 dose if negative)

 

Generally contraindicated2-4

HPV

Gardasil 9 (9 valent)

Between 9-26y, if at risk >26y and <45y

OK

Varicellad 

(chicken pox)

Varilrix or Varivax III (LIVE)

Check titre/history of chickenpox

Age <50y: 2 doses 12 weeks apart

Generally contraindicated2-4

Meningococcal

(meningitis)

MEN-C-ACYW-135 

(quadravalent conjugate) (0.5mL IM)

If <25y, no dose recorded

OK

OK1

Vaccines for High Risk Groups5

Hepatitis A /

Hepatitis B

Twinrix (HAV+HBV) (1mL IM)

Recombivax, Engerix-B (HBV only) (1mL IM)

0, 6-36 months

0, 1, 6 months

OK

OK1

Meningococcal

MEN-C-ACYW-135 

(quadravalent conjugate) (0.5mL IM)

Travel or At Risk

0, 8wks; booster every 5 years

OK

OK1

Cholera

Dukoral (oral)

Travel

Unnecessary – give antibiotics for treatment PRN

Typhoid

Typherix or Typhim Vi

Travel

OK

Vivotif (LIVE)

Generally contraindicated2-4

Japanese encephalitis

Ixiaro

Travel

OK

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).

Prevnar-20 is a new conjugated vaccine that has replaced Prevnar-13 and Pneumovax-23; it is covered by AB Health for

        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.

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. See further guidance for MMR vaccine.

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.

 Developed by Jill Hall, PharmD (Last updated: 2024-06-25)



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