Table 7.
Recommendations for vaccination in patients with active psoriatic arthritis (PICOs 56–57*)
| Level of evidence (evidence [refs.] reviewed)† | |
|---|---|
| In adult patients with active PsA needing vaccinations,‡ | |
| 1. Start the biologic and administer killed vaccines over delaying the start of biologic to administer killed vaccines (PICO 56) | Very low (121–126) |
| Conditional recommendation based on very-low- quality evidence; may consider delaying the start of biologic to administer killed vaccines due to patient preference based on patient belief about vaccine efficacy. | |
| 2. Delay the start of biologic to administer live attenuated vaccines over starting the biologic and administering live attenuated vaccines (PICO 57) | Very low (127) |
| Conditional recommendation based on very-low- quality evidence; may consider starting the biologic and administering live attenuated vaccines in patients with very active severe joint§ or skin¶ disease who prefer no delay in biologic initiation. |
Active psoriatic arthritis (PsA) is defined as disease causing symptoms at an unacceptably bothersome level as reported by the patient, and judged by the examining clinician to be due to PsA based on ≥1 of the following: swollen joints, tender joints, dactylitis, enthesitis, axial disease, active skin and/or nail involvement, and extraarticular inflammatory manifestations such as uveitis or inflammatory bowel disease.
When there were no published studies, we relied on the clinical experience of the panelists, which was designated very-low-quality evidence.
Vaccines as indicated by patient age, sex, and immunization history per recommendations from the Centers for Disease Control and Prevention and available at: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.
Because there are currently no widely agreed-upon definitions of disease severity, PsA severity should be established by the health care provider and patient on a case-by-case basis. For the purposes of these recommendations, severity is considered a broader concept than disease activity in that it encompasses the level of disease activity at a given time point, as well as the presence of poor prognostic factors and long-term damage. Examples of severe PsA disease include the presence of ≥1 of the following: a poor prognostic factor (erosive disease, elevated levels of inflammation markers such as C-reactive protein or erythrocyte sedimentation rate attributable to PsA), long-term damage that interferes with function (e.g., joint deformities, vision loss), highly active disease that causes major impairment in quality of life (i.e., active psoriatic inflammatory disease at many sites [including dactylitis, enthesitis] or function-limiting inflammatory disease at few sites), and rapidly progressive disease.
Because there are currently no widely agreed-upon definitions of disease severity, psoriasis severity should be established by the health care provider and patient on a case-by-case basis. In clinical trials, severe psoriasis has been defined as a Psoriasis Area and Severity Index (PASI) score (25) of ≥12 and a body surface area score of ≥10. In clinical practice, however, the PASI tool is not standardly utilized given its cumbersome nature. In 2007, the National Psoriasis Foundation published an expert consensus statement, which defined moderate-to-severe disease as a body surface area of ≥5% (68). In cases in which the involvement is in critical areas, such as the face, hands or feet, nails, intertriginous areas, scalp, or where the burden of the disease causes significant disability or impairment of physical or mental functioning, the disease can be severe despite the lower amount of surface area of skin involved. The need to factor in the unique circumstances of the individual patient is of critical importance, but this threshold provides some guidance in the care of patients.