The short answer
If you have rheumatoid arthritis and take treatment that lowers immunity, you will most likely need to discuss yearly flu vaccine, pneumococcal vaccine and shingles vaccine (two doses) with your doctor, because both the American and European guidelines count them among the most important vaccines in rheumatoid arthritis [1][2]. Live attenuated vaccines (such as measles, mumps and rubella, chickenpox and yellow fever) are the ones usually deferred or avoided while you are on immune-lowering treatment [1][8].
One point to hold on to: the timing of any vaccine around your treatment is your treating doctor's decision alone. This article explains what the guidelines say so you arrive at the visit knowing what to ask. It does not ask you to change, stop or delay any dose. A local Egyptian schedule can also differ from the foreign schedules, and your doctor reconciles the two.
Why infection matters more in rheumatoid arthritis
A population-based study compared 609 people with rheumatoid arthritis with 609 people without it and found more infections in the patients: the adjusted hazard ratio was 1.70 for objectively confirmed infections and 1.83 for infections that needed hospital admission. The most affected sites were bone, joints, skin and soft tissue, and the respiratory tract [4]. The cause is a mix of the disease itself and the treatments that calm the immune system [11].
Flu is a clear example. The World Health Organization estimates that seasonal flu causes about a billion cases a year, including 3 to 5 million severe cases and 290,000 to 650,000 respiratory deaths, that people with chronic conditions or weakened immunity are at higher risk of severe disease, and that yearly vaccination is recommended for the highest-risk groups [10].
So vaccines here are not a luxury: they are one of the few tools that lower the risk of certain infections before they happen. At the same time no vaccine protects against everything, so the infection warning signs (end of this article) stay important even after every vaccine.
The vaccines to discuss with your doctor
The 2022 American College of Rheumatology guideline is built on an evidence review, and the 2019 update of the European alliance of rheumatology associations recommendations says vaccination status should be reviewed every year and that non-live vaccines can be given regardless of treatment [1][2]. These are the main points.
Flu vaccine: recommended every year. If you are 65 or older, or 18 to 65 and on immune-lowering treatment, the American guideline conditionally prefers high-dose or adjuvanted vaccine over the regular dose. But any flu vaccine is better than none, and vaccination today is better than waiting for the higher-strength type [1].
Pneumococcal vaccine: the American guideline strongly recommends it for people under 65 on immune-lowering treatment [1]. The Centers for Disease Control and Prevention describe a sequence of a conjugate vaccine followed by the polysaccharide vaccine a year later (or 8 weeks later when immunity is weakened), or a single broader conjugate vaccine, and your doctor picks [9].
Recombinant shingles vaccine (non-live): the American guideline strongly recommends it for any adult over 18 on immune-lowering treatment, because shingles risk in rheumatoid arthritis is higher than in healthy older adults for whom it is advised. Short, mild flare-like symptoms around the shot are possible in some patients, and injection-site or whole-body reactions are fairly common [1]. The Centers for Disease Control and Prevention state two doses for adults 19 and over whose immunity is or will be weakened, the second usually 2 to 6 months after the first (1 to 2 months if faster completion is needed), and if more than 6 months have passed it is given as soon as possible without restarting the series [7].
Other vaccines: tetanus as for the general population, human papillomavirus vaccine conditionally for ages 26 to 45 if not vaccinated before, and hepatitis A and B if you have a risk factor, per the European recommendations [1][2]. For certain targeted tablets, a trial of 93 patients on upadacitinib with methotrexate who received two doses of the shingles vaccine found a satisfactory antibody response in 87.8% at week 16 [6]. COVID-19 vaccine is outside the 2022 guideline, which refers readers to separate guidance [1].
For more on the treatments themselves and why they are monitored, read our article on methotrexate for rheumatoid arthritis [1].
Read also: Methotrexate for rheumatoid arthritis: safety and monitoring
Live vaccines: the limits that apply
A live attenuated vaccine contains a weakened living virus or bacterium. In people whose immunity is suppressed by treatment, it can cause infection from the vaccine itself. That is why the American guideline conditionally recommends deferring live attenuated vaccines for people on immune-lowering treatment, and also advises that glucocorticoids be below 20 mg daily (prednisone equivalent) before any live vaccine other than flu [1].
The Centers for Disease Control and Prevention say that most forms of altered immunity should not receive live vaccines, and that all non-live vaccines can be given safely. They add that vaccines are best given at least 2 weeks before immune-lowering treatment starts, that live vaccines wait 3 months after such treatments end, at least 1 month after high-dose steroids, and that both live and non-live vaccines wait at least 6 months after anti-B-cell treatments. Their high-dose steroid definition is 2 mg per kg or 20 mg a day or more of prednisone for at least 14 consecutive days [8].
These are limits that frame your doctor's decision, not instructions to apply yourself. The best vaccination window is before an immune-lowering treatment starts, which is why your doctor may review your vaccine record before a new treatment, the subject of our article on what to do before biologic treatment.
One important precision: the injected flu vaccine is non-live and suitable, while the live nasal spray is the one usually avoided when immunity is suppressed. And because some live vaccines (such as measles or chickenpox) may need review before pregnancy, also read our article on rheumatoid arthritis and pregnancy planning.
Read also: Before biologic treatment for rheumatoid arthritis · Rheumatoid arthritis and pregnancy planning
Timing a vaccine with treatment: why your doctor decides
The American guideline separates one treatment from another. For most immune-lowering treatments, continuing treatment around non-live vaccines is conditionally preferred [1]. For methotrexate with flu vaccine specifically, the guideline conditionally recommends a dose-timing plan for 2 weeks after the vaccine if disease activity allows, with a flare-risk assessment and a shared decision between you and your doctor [1].
A randomised trial in people with rheumatoid arthritis made this comparison: a satisfactory antibody response was 51.0% in the group whose methotrexate timing was adjusted around the vaccine, versus 31.5% in the group who continued as usual (p=0.044). Flare rates were 24.1%, 21.2%, 34.1% and 38.8% across the four groups, with no significant difference [3]. This is trial data, not an instruction to you. Do not change your dose or its timing based on it yourself, because the balance between vaccine response and flare risk differs from patient to patient.
With anti-B-cell treatments, the guideline conditionally recommends giving the flu vaccine on schedule, and for other non-live vaccines conditionally prefers deferring them to the next treatment dose, with that dose delayed 2 weeks after the vaccine [1]. A trial in 103 patients showed that pneumococcal polysaccharide response was lower with rituximab (57% had at least a 2-fold rise for one or more serotypes, versus 82% on methotrexate alone), while tetanus response was similar (39.1% versus 42.3%) [5].
With steroids: at a prednisone-equivalent dose of 10 mg daily or less, giving any non-live vaccine is strongly recommended. Between over 10 and under 20 mg, it is conditionally recommended. At 20 mg or more, flu vaccine is conditionally recommended and other non-live vaccines may be considered for deferral [1].
All of this shows why a short "stop" or "carry on" answer is wrong: the decision depends on your current treatment and your disease activity. You can review the full treatment picture in our article on rheumatoid arthritis treatment options and monitoring.
Read also: Rheumatoid arthritis treatment options and monitoring
The local Egyptian schedule and your vaccine record
The sources we rely on here are American and European, and Egypt's national vaccine schedule can differ in the vaccines available and in timing. So treat this article as a frame for questions, and your doctor decides what suits you and what is available to you [1][2].
The European recommendations advise reviewing vaccination status every year, and vaccinating ideally when the disease is quiet and before immune-lowering treatment begins [2]. That leads to an easy practical step: gather your record before the visit. Bring the old vaccine card or photos of vaccination certificates, and note the date of your last flu shot, whether you had a pneumococcal vaccine before, whether you have had shingles, and whether you have travelled or will travel somewhere that requires a vaccine.
People who live with you: the European recommendations say household members should be vaccinated per national guidelines, except for the live oral polio vaccine [2]. Again this is a discussion with your doctor, especially if a child at home is due for vaccines.
To avoid confusion, do not rely on a vaccine given away from your treating doctor. If a vaccination centre offers you a live vaccine (such as yellow fever before travel), say that you are on immune-lowering treatment and ask your doctor before you accept.
Infection signs that need a call
Since infections are more frequent in rheumatoid arthritis and appear most in bone, joints, skin and the respiratory tract [4], make this message clear: call your doctor or go to the emergency room the same day if any of these signs appear.
Fever: a raised temperature or shivering, especially if it lasts more than a day or keeps rising.
A hot, swollen joint: one joint suddenly red, hot, swollen and very painful, because it could be a bacterial joint infection that needs urgent assessment. Our article on the hot swollen joint explains it in detail.
Chest symptoms: a new or worsening cough, shortness of breath, or chest pain with fever. Our article on lung symptoms in rheumatoid arthritis explains the causes and assessments.
Skin: a red area that spreads, is warm, or has pus, or a painful blistering rash on one side of the body (a sign of shingles).
Urinary or stomach symptoms: burning urine with fever, or severe persistent diarrhoea or vomiting that stops you drinking.
Any symptom that worries you and you cannot explain. Do not change your treatment because of a symptom on your own: tell your doctor and they decide. One reassuring fact: having vaccines in your record does not mean you are protected from everything, so watching for these signs stays important [4][10].
Read also: Lung symptoms in rheumatoid arthritis: when to get assessed
Preparing for the visit and booking
To get the most from the visit, here are questions to ask your doctor: which vaccines are missing from my record? Is the shingles vaccine suitable for me, and on which schedule? Is high-dose flu vaccine available? Does my current treatment affect the timing of any vaccine, and who decides? Is any live vaccine in my plan or my travel plan? [1][2]
At La Rose Clinics, rheumatology with Dr Shimaa Sherif is available in Maadi, and in Fifth Settlement on Wednesdays from 3:30 pm at CMC Medical Mall. Physiotherapy and DEXA scans are external referrals if your doctor requests them. Book your appointment to review your vaccine record and treatment with the doctor in person [1].
Read also: Book an appointment
