Table 2:

Vaccination Schedule Recommendations for Patients with Rheumatic Diseases:

	Vaccination recommendation	Recommended modification of DMARD therapy relative to vaccine timing based on guidelines and best available evidence^*, as compatible with disease activity.
Influenza	Yearly quadrivalent vaccination for all patients. ^†‡§ Patients older than 65 should receive the high-dose quadrivalent vaccine.^† ^*May consider high-dose vaccine for all immunocompromised patients. ^42,44	Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥ 6 months) and 4 weeks before the next dose.^§ Methotrexate: consider holding for two weeks after vaccination.^*^22,23
Pneumococcal	Recommended for all immunosuppressed patients. ^†‡§ Give 1 dose of PCV13 followed by PPSV23 at least 8 weeks later. Give a second PPSV23 dose 5 years after the first PPSV23 dose. ^†	Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥ 6 months) and 4 weeks before the next dose.^§ Methotrexate: consider holding MTX for two weeks after vaccination.^*
Herpes zoster	Recombinant zoster vaccine for adults over age 50.^†¶ Use live Zoster vaccine where recombinant is not available. Consider in all high-risk rheumatic disease patients. ^†§	Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥ 6 months) and 4 weeks before the next dose.^*
Hepatitis B	All nonimmune adults at risk for HBV infection. ^£†‡§	Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥ 6 months) and 4 weeks before the next dose.^§
Human papilloma virus	As per general population guidelines, especially for SLE patients.^§‡	Rituximab: vaccinate before starting rituximab, or as long as possible after the last dose (ideally ≥ 6 months) and 4 weeks before the next dose.^§
Tetanus	As per general population and consider for all rituximab treated patients.^§	Rituximab: vaccinate before starting rituximab.^§
Yellow fever	Avoid for immunocompromised patients.^‡§	N/A, contraindicated
SARS-CoV-2	All patients as per the general population. ¹³⁵	ACR guidance summary: ¹³⁵ Rituximab: as long as possible after the last dose, 2–4 weeks before the next dose. MTX: hold for 1 week after each mRNA dose; hold for 2 weeks after single-dose vaccine. MMF and JAK inhibitors: hold for 1 week after each vaccine dose. Abatacept subcutaneous: hold one week before and one week after the first vaccine dose, no interruption for the second vaccine dose. Abatacept intravenous: time the first vaccine dose 4 weeks after abatacept and postpone next infusion by 1 week; no adjustment for the second vaccine dose Cyclophosphamide: time cyclophosphamide 1 week after each vaccine dose. TNF, IL-6R, IL-1, IL-17, IL-12/23, IL-23, oral calcineurin inhibitors, belimumab^, azathioprine, sulfasalazine, leflunomide, hydroxychloroquine, apremilast, IVIG and glucocorticoids <20 mg/day^: no modification

Authors’ recommendations based on best available evidence

^†

2021 Advisory Committee on Immunization Practices recommendations¹²

^‡

2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis ⁴⁰

^§

2019 European League Against Rheumatism recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases ⁴¹

^¶

Per CDC guidelines, adults with immunocompromising conditions were not included in initial clinical trials and therefore no recommendations regarding vaccination age for this population was made. However, this may change in the future.

^£

Risk factors include: persons at risk through sexual exposure (sex partners of hepatitis B surface antigen positive persons, sexually active persons not in a long term monogamous relationship, persons seeking evaluation or treatment for a sexually transmitted disease, men who have sex with men), persons with a history of current or recent injection drug use, persons at risk for infection by percutaneous or mucosal exposure to blood (household contact or sexual partner who is hepatitis B surface antigen positive, resident or staff of a facility for the developmentally disabled, health care or public safety workers with anticipated risk for exposure to body fluids, patients with end-stage renal disease, persons with diabetes mellitus aged <60 or those over age 60 at the discretion of the treating physicians), travelers to endemic areas, patients with chronic liver disease or hepatitis C infection, incarcerated persons, and patients with human immunodeficiency virus.

^**

Data published since guideline development suggest that lower doses of prednisone and belimumab may adversely impact the SARS-CoV-2 mRNA vaccine immunogenicity. ⁸⁴