ACR Vaccine Recommendations: Current Best Practices

Vaccination is a crucial aspect of preventive healthcare, especially for individuals with rheumatic diseases who may have altered immune responses. Proper immunization reduces the risk of infections that can lead to complications or worsen underlying conditions. The American College of Rheumatology (ACR) provides updated recommendations to guide clinicians and patients in making informed decisions about vaccines.

Understanding these guidelines ensures better protection while considering factors such as disease activity, medication use, and age-related risks.

Vaccine Categories

Vaccines recommended by the ACR for individuals with rheumatic diseases fall into two primary categories: live attenuated and non-live vaccines. These classifications help determine suitability for patients on immunosuppressive therapies or with altered immune function.

Live attenuated vaccines, such as measles-mumps-rubella (MMR) and varicella, contain weakened pathogens that induce a strong immune response. While they typically provide long-lasting immunity, they pose risks for individuals on high-dose immunosuppressive treatments, as the attenuated virus could replicate unchecked. ACR guidelines generally advise against live vaccines for patients on biologic disease-modifying antirheumatic drugs (bDMARDs) or high-dose corticosteroids. If necessary, live vaccines should be given before starting immunosuppressive therapy to allow the immune system to respond effectively.

Non-live vaccines, which include inactivated, subunit, and recombinant formulations, are generally safer for immunocompromised individuals. Inactivated vaccines, such as influenza and hepatitis A, contain killed pathogens that cannot replicate, making them suitable for patients on immunosuppressive regimens. Subunit vaccines, like pneumococcal and hepatitis B, use purified components of the pathogen to stimulate immunity without introducing infection risk. Recombinant vaccines, such as human papillomavirus (HPV) and recombinant zoster vaccine (RZV), employ genetically engineered antigens to elicit an immune response, offering protection without the concerns associated with live vaccines.

Adjuvanted vaccines, a subset of non-live vaccines, enhance immune response using immune-stimulating substances. The adjuvanted influenza vaccine improves immunogenicity in older adults and immunocompromised individuals. The AS01B-adjuvanted recombinant zoster vaccine (Shingrix) is preferred over the live zoster vaccine for patients with rheumatic diseases due to its superior efficacy and safety. Studies show Shingrix maintains over 90% effectiveness in preventing herpes zoster, even in immunosuppressed populations.

Recommended Vaccines For Specific Conditions

Patients with rheumatic diseases face an increased risk of infections due to both their condition and immunosuppressive treatments. The ACR provides targeted vaccine recommendations based on specific rheumatic conditions to mitigate these risks.

For rheumatoid arthritis (RA) patients, pneumococcal vaccination is strongly advised due to their heightened susceptibility to pneumococcal pneumonia and invasive disease. RA patients receiving disease-modifying antirheumatic drugs (DMARDs) or biologics have a two- to four-fold increased risk of pneumococcal infections. The ACR recommends either the 20-valent pneumococcal conjugate vaccine (PCV20) or a sequential schedule of PCV15 followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23). Vaccination before starting immunosuppressive therapy enhances immune response.

Systemic lupus erythematosus (SLE) patients require additional precautions, particularly concerning live vaccines. Their increased risk of infections such as influenza, HPV, and herpes zoster underscores the need for comprehensive immunization. The recombinant zoster vaccine (RZV) is preferred over the live zoster vaccine, as SLE patients have a 1.5- to 3-fold higher risk of shingles. HPV vaccination is strongly encouraged for younger patients due to their elevated risk of persistent infection and associated malignancies.

Patients with vasculitis, especially those on high-dose corticosteroids or cyclophosphamide, require enhanced protection against bacterial and viral pathogens. Influenza vaccination is a priority, as respiratory infections can exacerbate disease flares. Hepatitis B vaccination is recommended for patients receiving rituximab or other B-cell depleting therapies, as these treatments increase susceptibility to hepatitis B virus (HBV) reactivation. The ACR advises screening for HBV before initiating such therapies and administering a three-dose hepatitis B vaccine series if needed.

Scheduling Considerations

Determining the optimal timing for vaccinations in individuals with rheumatic diseases requires planning to maximize efficacy while minimizing risks. The ACR emphasizes aligning vaccine administration with disease stability, medication schedules, and the likelihood of achieving a strong immune response.

Vaccines should ideally be given at least two to four weeks before starting an immunosuppressive regimen to ensure immune priming. If immunosuppression is already underway, clinicians may need to delay certain vaccines or opt for alternative formulations that remain effective despite immune modulation. This is particularly relevant for multi-dose vaccines like hepatitis B or pneumococcal conjugate vaccines, where proper spacing is crucial for protection.

Seasonal variations also influence vaccination schedules. Influenza activity peaks between December and February in the Northern Hemisphere, prompting the Centers for Disease Control and Prevention (CDC) to recommend annual vaccination by the end of October. For immunosuppressed individuals, earlier vaccination may be preferable to account for potential delays in immune response. The recent availability of respiratory syncytial virus (RSV) vaccines for older adults also necessitates strategic planning, particularly for those with underlying pulmonary conditions.

Coordination With Rheumatic Medications

Balancing vaccination schedules with rheumatic medication regimens requires careful planning to avoid interactions that could compromise treatment efficacy or immune protection. The ACR provides guidance on navigating these complexities, particularly for patients on biologic DMARDs, Janus kinase (JAK) inhibitors, or high-dose corticosteroids.

For patients on bDMARDs such as tumor necrosis factor (TNF) inhibitors or interleukin-6 (IL-6) blockers, non-live vaccines can generally be administered without interruption. However, some studies suggest pausing therapy temporarily may enhance vaccine-induced immunity, particularly for agents like rituximab, which depletes B cells and can impair antibody production. ACR guidelines recommend scheduling vaccinations at least four weeks before starting rituximab and, if already on treatment, administering vaccines approximately six months after the last infusion to maximize response.

JAK inhibitors, including tofacitinib and baricitinib, present additional considerations due to their broad immunomodulatory effects. While vaccine efficacy is often preserved, some data indicate a slightly reduced antibody response to certain formulations, such as influenza and pneumococcal vaccines. Clinicians may opt to administer vaccines before starting JAK inhibitors when possible, though the risk of delaying therapy must be weighed against potential benefits.

Pediatric And Adolescent Approaches

Vaccination strategies for children and adolescents with rheumatic diseases must consider both developmental immunology and disease management. The ACR emphasizes completing routine childhood immunizations before initiating immunosuppressive therapy whenever possible. Early protection is particularly important for live vaccines, as these may become contraindicated once treatment begins.

For children with juvenile idiopathic arthritis (JIA), pneumococcal and meningococcal vaccines are prioritized due to the increased risk of invasive bacterial infections associated with long-term immunosuppressive therapy. JIA patients on methotrexate or biologics are more susceptible to Streptococcus pneumoniae infections, making pneumococcal conjugate vaccines (PCV13 or PCV15) essential. Meningococcal ACWY and MenB vaccines are recommended, particularly for those on complement-inhibiting therapies like eculizumab, which heightens the risk of meningococcal disease.

Adolescents with SLE also require additional precautions, particularly regarding HPV vaccination. SLE patients face an increased risk of persistent HPV infection and cervical dysplasia, underscoring the need for early vaccination. The recombinant zoster vaccine (RZV) is another consideration for adolescents with conditions predisposing them to herpes zoster, especially those on prolonged corticosteroid therapy.

Adult And Geriatric Approaches

Vaccine recommendations for adults and older individuals with rheumatic diseases focus on maintaining protection while accounting for age-related immune decline, which can reduce vaccine efficacy. The ACR advises adapting immunization strategies to address the unique risks faced by these populations.

For adults with RA, annual influenza vaccination is strongly recommended, as respiratory infections can trigger disease flares and lead to hospitalization. RA patients have a significantly higher risk of influenza-related complications, making both standard-dose and adjuvanted influenza vaccines viable options. The pneumococcal vaccination series is also emphasized, particularly for those over 50, as RA patients on immunosuppressive therapy are more likely to develop pneumococcal pneumonia.

Geriatric patients with vasculitis or systemic sclerosis may benefit from the recently approved RSV vaccine, which reduces severe lower respiratory tract infections in older adults. Herpes zoster vaccination with RZV is particularly important for individuals over 60, given the increased incidence of shingles and postherpetic neuralgia in this demographic.