As flu season approaches, you might be asking: Is it safe to get the flu vaccine if you’re currently taking rheumatology meds? What about the pneumonia vaccine? Or the shingles vaccine? There’s a lot of confusing information out there, so I want to help you make the most informed choice.
If you’ve been diagnosed with RA, Lupus, MCTD, UCTD, Sjogren’s, Vasculitis, Myositis, or any other autoimmune rheumatic process and are currently being treated by a traditional Rheumatologist, chances are you’re now what we in the medical community consider “immunocompromised” (immu – no – compromised).
In other words, you WON’T BE ABLE to mount the same immune response to fight off infections as those who are not immunocompromised.
The most commonly used Rheumy medicines we would consider “immunosuppressants,” or those that increase your risk of infection and a need for vaccination, include:
Sulfasalazine (Azulfidine) Methotrexate
Arava (Leflunomide) Imuran (Azathioprine)
Cyclosporin Cytoxan (cyclophosphamide)
Plaquenil (Hydroxychloroquine) is typically NOT considered an immunosuppressant.
Sulfasalazine is classified as a weak immunosuppressant.
Humira Enbrel Xeljanz
Remicade Simponi Cosentyx
Cimzia Orencia Taltz
Kineret Actemra Stelara
Although there are several theories about what triggers people to “get” these Rheumatic conditions, we still don’t exactly know what the underlying issue is. Is it an infection? Environmental? Genetics? Diet or Lifestyle Choices? Or better yet, is it a combination of several factors (this is my current opinion . . . and, yes, we all have an opinion). Unfortunately, we still don’t have THE answer. Perhaps the root cause is different from one individual to the next.
So, for the time being, what we do know about these conditions is that they are the result of our immune system going awry and attacking ourselves; therefore, the current traditional treatment approach is to suppress that self-attacking immune response (that is, the immune system), and this leaves us “immunocompromised.”
This brings us to vaccinations.
I often get asked, ‘Can I get a flu shot? What about the pneumonia or shingles vaccine?’
So, I wanted to cover the three most commonly asked questions about vaccines, flu, pneumonia, and Shingles, as well as the current recommendations.
When in doubt, just remember this: if you are on any of the immunosuppressive meds listed above. . . just say NO to “live” vaccines!
But let’s look a little more closely at the most recent guidelines from the Advisory Committee on Immunization Practices, which were published in 2016 in the Annals of Internal Medicine, as well as the American College of Rheumatology guidelines from 2015, which appeared in Arthritis Rheumatology in 2016.
ACIP / ACR have the same recommendations for the flu vaccine
Flu vaccine: Intranasal spray vaccine — NO
Intramuscular (IM) vaccine — YES
Yes, according to both entities, it is okay to take the IM or “dead” flu vaccine while on medications.
Pneumonia vaccine: Patients should not be on immunosuppressants for at least two weeks before receiving the vaccine.
Pneumonia vaccine: Okay to take during the use of medications.
ACIP / ACR recommendation:
Shingles vaccine (Zostavax – LIVE vaccine. . .the older one):
Hold medications for 1 month prior to getting the vaccine.
Shingles vaccine (Shingrix – inactivated / non-live vaccine), the new one—two shots:
Okay to take during the use of medications except for Rituxan—the current recommendation is to take at least a month before.
Okay to take if the patient previously took Zostavax.
In general, if you HAVE to take a “live” vaccine, the current recommendation is to be off any and all immunosuppressants for at least 4 -12 weeks before receiving the vaccine.
But wait, if I’m off my meds, won’t I flare? Herein lies the problem and, to be honest with you, after my search of the most recent recommendations from various organizations, there is still a lot of confusion about what THE ANSWER is—which is frustrating for docs and patients alike.
Next question: What are the current recommendations for WHEN I should get my vaccines?
I have included a link below from the CDC (Center for Disease Control) who base their recommendations largely off the ACIP (Advisory Committee on Immunization Practices).
1. Yes, people with autoimmune rheumatic conditions have a greater risk for infection.
2. Other factors such as other medical conditions, age, environment, and lifestyle choices also increase your risk of having a serious infection.
3. Steroids use carries the greatest risk for infection. The higher the dose and the longer you are on them, the higher the risk.
4. Higher doses of immunosuppressive medications carry a greater risk for infection.
5. Severity of disease is directly proportional to infection risk—there is a lower risk of infection with mild disease than with severe disease.
So, what choices can you make to reduce your risk?
First, keep your risk in mind and. . .
- Try to avoid those who have an active infection and use good hygiene such as hand washing or wearing a mask if you have to be near them.
- Make healthier choices if you’re not already doing so—give up nicotine, get good rest, clean up the diet, and participate in routine exercise.
- Get Vaccinated: The flu killed 80,000 people between 2017-2018, and pneumonia took about 50,000 people.
- Finally, consider supplements such as Vitamin C, E, A, and D, as well as clove, oregano, thyme, cinnamon, cumin, and ginger (Int J Mol Sci. 2017 Jun; 18(6): 1283.)