What You Need to Know About RA and Vaccinationsby Lene Andersen, MSW Patient Advocate
People who live with rheumatoid arthritis (RA) have approximately double the risk of infection compared to the general population. This is partly due to the fact that many of us take immunosuppressant medications, such as methotrexate and biologics. However, it's also theorized that the immunologic response that happens in autoimmune diseases, such as RA, may contribute to this vulnerability. One of the tools we can use to manage the risk of infection is vaccinations.
An important trio of vaccines
Most rheumatologists will recommend that you get an annual flu shot, as well as the pneumonia vaccine, and a tetanus shot. These three vaccines are important tools in helping you stay healthy, especially when you take immunosuppressants. All three offer protection against conditions that can turn nasty, evolving into potentially life-threatening complications. Getting an easy injection with minimal side effects can help you avoid feeling crappy, at minimum, and may even keep you from ending up in the hospital.
The flu shot
The flu makes you feel miserable and has the potential for serious complications, especially for the very young, the very old, and people with suppressed immune systems. The best way to reduce the incidence of flu is to get vaccinated when the flu shot becomes available. The Centers for Disease Control and Prevention (CDC) recommends that you get vaccinated by the end of October. Getting the vaccine reduces your risk of catching the flu by up to 60 percent. This protects you, as well as the people around you.
Effectiveness of the flu vaccine
The flu shot is developed each year based on research and monitoring which influenza types circulated that year. The decision about which viruses to use to develop the vaccine is made many months before flu season. Flu viruses constantly change, so there may be variations in effectiveness. Talk to your doctor about whether the annual flu vaccine includes protection against the H1N1 influenza or whether you need a separate shot.
Immunosuppressant medication and the flu vaccine
Studies indicate that people taking methotrexate and most biologics can respond adequately to the flu vaccine, although the level of protection may be somewhat reduced. However, the biologic rituximab does interfere significantly with developing antibodies after getting the flu shot. This vaccination needs to be carefully timed with administration of rituximab. Live vaccinations (that is, the nasal spray) is not recommended for people with RA in general, and particularly those taking biologics.
The pneumonia shot
Because RA can affect the lungs, the pneumonia vaccine is especially important. There are two vaccines against pneumonia: the pneumococcal conjugate (PCV13) and pneumococcal polysaccharide (PPSV23). They both protect against 23 different types of pneumococcal bacteria and PCV13 also protects against pneumococcal disease, which can cause meningitis. Pneumonia vaccination is also strongly recommended if you have a suppressed immune system.
When to get the pneumonia shot
Ask your doctor whether you need both pneumonia vaccines or if one is enough. If you need both, the CDC recommends getting first the pneumococcal conjugate vaccine, followed by the pneumococcal polysaccharide shot one year later. Rheumatologists recommend a second injection of the pneumonia vaccine to those taking immunosuppressants five years after the first shot. Studies show that people taking immunosuppressant drugs for RA do not experience a reduced response to the pneumonia shot.
The tetanus shot is included in a variety of vaccines, usually also protecting against diphtheria and pertussis. Tetanus, also called lockjaw, is caused by the bacteria Clostridium tetani. It can be found in dust, soil, and manure. If it enters the body through a cut in the skin, it can cause tetanus, which has the potential to be life-threatening. In order to be fully protected, you need to get the tetanus shot every 10 years.
Live vaccines and immunosuppressants
Live vaccines have a weakened version of the disease-causing microbe. It doesn’t make you sick and may work better to teach the immune system to protect against that disease. Live vaccines include nasal flu vaccine, live shingles (Zostavax®) and chickenpox, yellow fever, oral polio, MMR (measles, mumps, and rubella) and others. When you’re on an immunosuppressant drug, live vaccines may increase the risk of getting the illness that you’re being vaccinated against. Killed or inactivated, sugar, and protein vaccines are considered safe.
RA and the shingles vaccine
If you have been exposed to chickenpox at some point in your life, the virus will be dormant in your system and may cause shingles. People with RA have twice the risk of contracting shingles than the general population. Doctors usually recommend getting vaccinated against shingles prior to starting biologics if you are planning on getting the live vaccine (Zostavax®). However, there is a newer shingles vaccine called Shingrix which is not a live vaccine. It is a recombinant zoster vaccine. It is given in two injections separated by two to six months, to prevent shingles and the complications from the disease. Your doctor or pharmacist can give you Shingrix as a shot in your upper arm.
Suppressed immune systems and vaccination
It is generally recommended to get a variety of vaccinations before starting treatment for RA, either with a biologic or a non-biologic DMARD. The theory is that this will maximize your response to the vaccines, which again could help you respond better to later vaccinations. As well, receiving the live shingles vaccine before starting immunosuppressant treatment will protect you against reacting to the live vaccine by developing shingles or an infection. However, the shingles vaccine (Shingrix) can be used before or during the immunosuppressive treatment as it is not a live vaccine.
Egg allergy and flu vaccine
As with most medications, vaccines have a caution to not be administered if you are allergic to one of the ingredients. Some vaccines, including the flu shot, are cultivated in eggs. If you have an egg allergy, it's quite possible that you may tolerate this vaccine; however, if you've had a reaction in the past, you should have a conversation with your doctor about how to manage the risk. You can also receive the recombinant influenza vaccine, which does not contain egg proteins.
Travel vaccines and RA
Most travel vaccines are killed or inactivated and should be safe regardless of the medication you take. A few are live, such as yellow fever and polio, which are not recommended if you have a suppressed immune system. If you are going to an area that requires the yellow fever vaccine, talk to your doctor about the risks and, should you choose to go, how to manage them. You will also need a waiver letter. The yellow fever vaccine is grown in eggs — if you have an egg allergy, speak to your doctor.