Table 1.
2012 ACR Recommendations regarding the use of vaccines in patients with RA starting or currently receiving DMARDs or biologic agents*
| Killed vaccines | Recombinant vaccine | Live attenuated vaccine | |||
|---|---|---|---|---|---|
| Pneumococcal† | Influenza (intramuscular) | Hepatitis B‡ | Human papillomavirus | Herpes zoster | |
| Before initiating therapy | |||||
| DMARD monotherapy | ✓ | ✓ | ✓ | ✓ | ✓ |
| Combination DMARDs§ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Anti-TNF biologies¶ | ✓ | ✓ | ✓ | ✓ | ✓ |
| Non-TNF biologics# | ✓ | ✓ | ✓ | ✓ | ✓ |
| While already taking therapy | |||||
| DMARD monotherapy | ✓ | ✓ | ✓ | ✓ | ✓ |
| Combination DMARDs | ✓ | ✓ | ✓ | ✓ | ✓ |
| Anti-TNF biologies¶ | ✓ | ✓ | ✓ | ✓ | Not recommended** |
| Non-TNF biologics# | ✓ | ✓ | ✓ | ✓ | Not recommended** |
Evidence level was C for all of the vaccination recommendations. For definitions and key terms, please refer to Table 2. DMARDs = disease- modifying antirheumatic drugs;
= recommend vaccination when indicated (based on age and risk); anti-TNF = anti-tumor necrosis factor.
The Centers for Disease Control and Prevention also recommends a one-time pneumococcal revaccination after 5 years for persons with chronic conditions such as rheumatoid arthritis (RA). For persons ages >65 years, one-time revaccination is recommended if they were vaccinated >5 years previously and were age <65 years at the time of the primary vaccination.
If hepatitis risk factors are present (e.g., intravenous drug abuse, multiple sex partners in the previous 6 months, health care personnel).
DMARDs include hydroxychloroquine, leflunomide, methotrexate, minocycline, and sulfasalazine (listed alphabetically) and combination DMARD therapy included double (most methotrexate based, with few exceptions) or triple therapy (hydroxychloroquine 4- methotrexate + sulfasalazine).
Anti-TNF biologies include adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab (listed alphabetically).
Non-TNF biologies include abatacept, rituximab, and tocilizumab (listed alphabetically).
According to the RAND/UCLA Appropriateness Method, panel members judged it as "not appropriate" and therefore it qualifies as "not recommended" (median score on appropriateness scale was 1).