RA & Vaccinations in the COVID-19 Pandemic

Keeping up with your vaccinations is always a smart move when you have an autoimmune disease like rheumatoid arthritis (RA), but getting immunized for common infections like influenza (flu), pneumonia and shingles is especially important during the COVID-19 pandemic. Having RA and the medicines you take to treat it may increase your risk for infections and reduce your immune system’s ability to fight sickness.

“Since immune system function can be suppressed by RA and the medications used to control RA, any disease that is usually kept in check by the healthy immune system can become a greater concern in patients with RA,” says Joel Thome, PharmD, pharmacist and assistant professor of pharmacology at Pacific Northwest University of Health Sciences in Yakima, Washington. This can prove particularly dangerous with the current threat of the new coronavirus.

Despite the higher risk of acquiring an infection or virus, vaccination rates among people with RA historically have been low, according to a study by Eric Ruderman, MD, and his colleagues at the Northwestern University Feinberg School of Medicine in Chicago. In the past, only about half of patients had received the pneumonia vaccine, and just 8% were vaccinated against the virus that causes herpes zoster (shingles).

Why are so few RA patients getting their vaccines? “We found that a lot of it is awareness. It’s not so much hesitancy on the part of patients to get vaccinated, but frankly, their physicians hadn’t recommended it,” says Dr. Ruderman.

Rheumatologists may not initiate the vaccine discussion because they assume the patient’s primary care doctor or pharmacist will handle it.

“Better patient education and awareness can help patients be proactive about discussing vaccines with their doctor,” says Kevin Winthrop, MD, MPH, professor of infectious diseases at Oregon Health & Science University in Portland.

Patients also might worry that vaccinations may trigger flares, Dr. Winthrop says, “but we really haven’t seen that.” Most vaccine side effects are mild, whether you have RA or not. They can include soreness at the injection site, fever and achiness.

Because RA can affect lung function, Thome says, “Vaccines for preventable diseases of the respiratory system can be particularly important, like the flu shot and pneumonia vaccine.” People who are immunocompromised probably should play it safe by avoiding live vaccines, such as the nasal flu vaccine, FluMist.

Pneumonia is an infection of the lungs, but a common cause is the pneumococcal bacterium. The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccines for adults older than 65 and those who are immunocompromised. Talk to your doctor about the best time for your vaccination and whether you should be revaccinated after five years.

If you’re over 50, you also need the herpes zoster vaccine. After you’re exposed to chickenpox in childhood, the virus lies dormant and can reawaken decades later in the form of the painful, blistering disease called shingles. Having lupus or RA or taking immunosuppressant drugs used to treat these diseases – especially anti-tumor necrosis factor (anti-TNF) biologics like infliximab (Remicade) and etanercept (Enbrel) – raise your risk of shingles. The diseases and medications weaken the immune system, making it easier for the virus to reactivate. If you take a biologic, talk to your doctor before getting a vaccine for shingles.

Zostavax, which is given as a single injection, was the primary vaccine for shingles before the 2017 introduction of Shingrix, a more effective and preferred vaccine, according to the CDC. Shingrix, which is given in a series of two injections, is an inactive vaccine, unlike Zostavax, which is live.

“To my knowledge, there haven’t been reports of significant problems, but the concern is if your immune system is compromised by a biologic and you get a live vaccine, you could get sick from the vaccine,” Dr. Ruderman says.

Dr. Winthrop and his team recently completed a large study that found Zostavax is safe for patients who take methotrexate, prednisone and anti-TNF therapies, although it is less effective. According to the CDC, however, Zostavax is no longer sold in United States as of July, although some pharmacies still have it in stock.

Dr. Winthrop and colleagues are starting several studies of Shingrix with various disease-modifying antirheumatic drugs (DMARDs), but information is limited so far. It is “likely to be safe, but theoretically could cause autoimmune disease flares, although this has not been an issue in limited observational reports to date,” Dr. Winthrop says. “Efficacy is likely reduced in the RA population as compared to general population due to immune status,” he adds, “although it might not be reduced much or all.”

Your doctor will recommend you get vaccinated before you start RA treatment. Many inflammatory arthritis drugs, including DMARDs and biologics, suppress your immune system and increase your risk for infection, and some of these drugs also can reduce your body’s response to certain vaccines — including influenza, herpes zoster and pneumococcal polysaccharide (PPSV23).

Ideally, you want to get vaccinated when your arthritis is well-controlled. Severe or uncontrolled inflammatory arthritis might lower your immune response, resulting in less protection.

“But of course, it depends on the vaccine, the disease and the patient,” cautions Thome. “Since patients with RA should receive their flu shot every year before flu season, sometimes it is necessary to give this vaccine even when disease symptoms are active.”

Regardless, your disease should never stop you from getting the vaccines you need to stay healthy. “There may be some lessening of response, but not enough to be meaningful and not enough to affect the decision to do it,” Dr. Ruderman says.

Considering the average doctor visit lasts just 15 minutes and you have many RA concerns to address, the subject of vaccines can easily be overlooked. Write a note reminding yourself to bring them up. If your doctor doesn’t initiate the discussion, you should.

Also make sure your electronic medical record is updated to help your doctors keep track of the vaccines you’ve had. Ask your rheumatologist or primary care doctor to send you a reminder when you’re due for your shots so you don’t neglect them.

 

Vaccine	What it Prevents	Doses	Who Shouldn’t Get It
Inactivated influenza vaccine	Flu	Once a year, in the early fall	People with RA should avoid the live FluMist vaccine
Pneumococcal 13-valent conjugate (PCV13)	Pneumonia, meningitis, bloodstream infection (sepsis)	One dose	N/A
Pneumococcal polysaccharide (PPSV23)	Pneumonia, meningitis, bloodstream infection (sepsis)	One or two doses	N/A
Herpes zoster (Shingrix)	Shingles	Two doses two to six months apart at age 50 or older	N/A
Hepatitis B	Hepatitis B	Three doses	N/A

AUTHOR: Stephanie Watson

Related Resources:

• Having RA Increases Shingles Risk
• Arthritis Patients: Get Your Flu Shots
• Myth of Truth: You Are at Greater Risk of Cold and Flu