TABLE 2.
Reviewed practice guidelines citations, with focus on non‐live vaccinations
| Article | Vaccine type | Patient population | Safety | Immunogenicity | Efficacy | Timing /DMARD cessation | Post‐vaccination antibody testing | Vaccination of household contacts |
|---|---|---|---|---|---|---|---|---|
| Furer V, et al. 29 | Non‐live | PRD on IS/ DMARD/ GC | Influenza (LOE a 2b‐4) and PCV (LOE 4) deemed safe |
Good for influenza (LOE 1b‐4) and PPSV23 (LOE 1b‐4) Influenza: reduced by RTX, ABA PPSV23: reduced by RTX, ABA, TOF, GOL PCV13: reduced by MTX |
Influenza (LOE 2a‐5), PPSV23 (LOE 1b‐4) No data for MTX, TNFi, B cell depletion, belimumab, tocilizumab, abatacept, tofacitinib, glucocorticoids |
Quiescent dx Prior to IS, in particular B cell depleting therapy (6 mo post‐RTX, 4 wk before next dose of RTX) No DMARD cessation |
‐ | Yes, except for oral polio (LOE NA) |
| Seo YB, et al. 22 | Non‐live | PRD on IS/ DMARD/ GC | Similar risk as general population (Influenza LOE: b mod; pneumococcal LOE : low) |
Similar or slightly lower than that of healthy individuals. Pneumococcal: reduced by MTX, RTX, ABA |
Influenza and pneumococcal |
Stable dx (LOE: very low) Prior to IS (LOE : very low) Before ABA and ≥4 wk before RTX No DMARD cessation |
‐ | Yes |
| Guerrini G, et a. 28 | Influenza and pneumococcal | PRD on IS/ DMARD/ GC | Influenza and pneumococcal deemed safe (LOE c 2) |
Pneumococcal: reduced by MTX, RTX, ABA, TOF, MMF, AZA, CyC, high dose GC (LOE 2) Influenza: reduced by RTX, ABA, high dose GC (LOE 2) |
‐ |
Stable dx (LOE 2) Pneumococcal: before IS and ≥4 wk before RTX (LOE 2) |
‐ | ‐ |
| Papp KA, et al. 24 | Non‐live | PRD on IS/ DMARD/ GC | ‐ | ‐ | ‐ |
2 wk before IS (LOE 4 mod) RTX: 5 mo post‐RTX and ≥4 wk prior to RTX (LOE low) |
‐ | ‐ |
| Holroyd CR, et al. 26 | Non‐live | RA, PsA, axSpA | No flare of RA with Influenza |
Influenza: reduced by ETN and INF, RTX, ABA Pneumococcal: reduced by MTX, RTX, ABA (LOE d 1C) |
‐ | ‐ | ‐ | ‐ |
| Keeling SO, et al. 25 | Influenza | SLE | Trivial number of SLE flares with influenza (LOE e mod) | ‐ | Influenza (LOE mod) | ‐ | ‐ | ‐ |
| Singh JA, et al. 21 | Non‐live | RA on DMARD/ GC | ‐ | Reduced by RTX and possibly MTX (LOE d very low) | Killed vaccine (LOE very low) | No DMARD cessation needed (LOE very low) | ||
| Bühler S, et al. 30 | Non‐live | PRD on IS/ DMARD/ GC | No flare nor trigger of rheumatic disease, (LOE d low) | Reduced by DMARD/ GC especially MTX, RTX, ABA (LOE mod) | ‐ |
When the IS lowest (LOE low) Before ABA RTX: 6 mo post‐RTX for revaccination, 12 mo post‐RTX for primary vaccination |
4‐6 wk post vaccine (LOE NA) | Yes (LOE NA) |
| Rubin LQ, et al. 23 | Non‐live | IC | ‐ | Influenza: reduced within 6 mo of RTX (LOE 5 mod) | ‐ | ≥2 wk before IS (LOE mod) | ‐ | Yes (LOE high) |
| Centers for Disease Control & Prevention 31 | Pneumococcal | IC | ‐ | ‐ | ‐ | ‐ | ||
| Heijstek MW, et al. 27 | Non‐live | PRD on DMARD /GC | No flare of rheumatic disease or serious adverse events in comparison to healthy subjects |
Influenza: reduced by GC > 10 mg/d (LOE c 3), AZA, HCQ, CYC (LOE 2), RTX (LOE 2) Pneumococcal: reduced by MTX (LOE 2), RTX (LOE 1b) |
‐ | Before RTX (LOE 1b‐2) |
Influenza and pneumococcal: on RTX (LOE 1b‐2), GC ≥ 2 mg/kg or 20 mg/d for ≥2 wk (LOE 3), ±TNFi (LOE 2) PPSV23: On MTX (LOE 2) |
‐ |
Abbreviations: ABA, abatacept; axSpA, axial spondyloarthritis; Aza, azathioprine; CYC, cyclophosphamide; DMARD, disease modifying anti‐rheumatic drugs; dx, disease; GC, glucocorticoid; IC, immunocompromised; IS, immunosuppression; JAKi, inhibitors of Janus kinase; LOE, level of evidence; MMF, mycophenolate mofetil; mod, moderate; mo, months; MTX, methotrexate; NA, non‐available; PCV, pneumococcal vaccination; PRD, people with rheumatic diseases; PsA, psoriatic arthritis; RA, rheumatoid arthritis; RTX, rituximab; SLE, systemic lupus erythematosus; TNFi, tumor necrosis factor inhibitors; TOC, tocilizumab; wk, weeks.
Oxford Centre for Evidence‐Based Medicine – levels of evidence. 45
Level of evidence as defined: High – very unlikely to change confidence in the estimate of effect by an additional study; Moderate – likely to change confidence in the estimate of effect by an additional study; Low – highly likely to change confidence in the estimate of effect by an additional study; Very low – not sure about confidence in the estimate of effect
Level of evidence as defined: 1a – meta‐analysis of randomized controlled trials (RCT); 1b – RCT; 2 – prospective controlled intervention study without randomization; 3 – descriptive/analytic study (including case‐control, cross‐sectional, case series); 4 – expert committee reports or opinion or clinical experience of respected authorities or both
GRADE level of evidence. 32
Level of evidence as defined: High – consistent evidence from well performed RCTs or exceptionally strong evidence from unbiased observational studies; Moderate – evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies; Low – evidence for at least 1 critical outcome from observational studies, RCTs with serious flaws or indirect evidence; Very low – evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence.
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