Vaccinating patients with autoimmune diseases

Vaccine preventable diseases, especially respiratory infections, occur at higher frequency in patients with rheumatic diseases who are immunosuppressed. The focus of this review is to highlight vaccinations that patients with rheumatic diseases should optimally receive, with a focus on efficacy and safety of vaccines.

In general, vaccines are effective in reducing the burden of infection. However, due to underlying immunosuppression, their efficacy is most likely reduced compared to the general population. This is even true of the novel vaccines, mRNA and subunit vaccines. Emerging evidence, particularly for withholding methotrexate for 1-2 weeks post vaccination can improve immunogenicity without significantly increasing the risk of disease flare. Administration of live vaccines continue to provide clinicians a challenge especially in the setting of recent measles outbreaks. Assessing underlying degree of immunosuppression and following national guidelines can help clinicians vaccinate these patients safely. If this is not possible, then measles immunoglobulin can be administered.

Vaccination is an important part of infection reduction strategies for the rheumatologist to consider during a consultation as the number of vaccines available for infective conditions increases. High dose prednisolone, B cell depleting therapies, and methotrexate have the most evidence for reduced vaccine responses and where feasible, attempts should be made to vaccinate when immunosuppression is thought to be lower.