Your Guide to Vaccines and Inflammatory Arthritis

“When people have a chronic condition, I think they just naturally question whether or not they’re a good candidate for getting a vaccine,” says Dr. Vivien Brown, a family doctor in Toronto. She points to the guidelines issued by the National Advisory Committee on Immunization (NACI), which in turn, are used by the Public Health Agency of Canada. “It’s a group of scientists and specialists from across the country that come out with statements on various [immunization] issues…So when someone goes to their doctor, it’s not the doctor saying yes or no. It really is guideline-based and I think that’s extremely reassuring.” 

Why are vaccines important for people living with arthritis? “When people are successful in getting that chronic disease in remission, an episode of another disease may trigger that remission, may impact on that remission. So, the value of a vaccine is not just preventing the disease it’s designed for, but it’s also helping people to stay healthy in a general way, which hopefully will keep their disease in remission,” says Dr. Brown. She adds that vaccinations are part of good health practices, which include sleep, nutrition, exercise, and stress management. 

The yearly influenza vaccine or flu shot is recommended. Beyond that, if you’re living with inflammatory arthritis, here are a few other issues about vaccines to discuss with your primary care provider or your rheumatologist.

Medications

There are two main types of vaccines. Live attenuated vaccines contain a living but weakened strain of a bacteria or virus. Meanwhile, inactivated vaccines are made from dead viruses or bacteria. In a 2019 article in the Canadian Medical Association Journal, the authors write that “inactivated vaccines are safe and generally effective in patients receiving disease-modifying antirheumatic drugs [DMARD],” “ideally, vaccine administration should be completed before treatment and during stable disease, but do not unduly delay or hold DMARD treatment,” and “live vaccines should be avoided in patients receiving biologic DMARDs.” They add that all vaccinations can be given on the same day, and that “both serious and mild adverse events such as nausea, fever and myalgia occur at rates similar to those in people without autoimmune disease.”

So, taking some arthritis medications, including biologics and long-term corticosteroids, can mean that you’re not a good candidate for vaccines that contain a live virus. Fortunately, says Dr. Brown, most of the major adult vaccines do not contain a live virus. For example, the newer shingles vaccine for adults age 50 and up is made with an inactivated virus, so it is safe for someone who is immunosuppressed, she says. It’s important to note that contraindications may exist though, so talk to your health care provider.

Similarly, vaccines for hepatitis A and B, which are recommended for international travelers and for people in higher-risk populations, do not contain a live virus. On the other hand, a more uncommon travel vaccine for yellow fever, does contain a live virus, so is not recommended.  

Routine Adult Vaccinations

Immunize Canada recommends tetanus and diphtheria vaccinations for all adults every 10 years, so check in with your doctor to see if that’s right for you. A pertussis (whooping cough) vaccination is also recommended once in adulthood and during each pregnancy. Generally, in Canada these three vaccines, known as TDAP, are given together in one dose. These are inactivated vaccines. 

A pneumococcal vaccine (another inactivated vaccine) helps protect against strains of pneumococcal bacteria, which can lead to serious conditions like meningitis and pneumonia and is recommended for all adults age 65 and older, every five years. This vaccine is also recommended for people of any age who live in an assisted care facility. Because people living with inflammatory arthritis often have an increased risk of infectious disease, your health care provider may suggest you get this vaccine before age 65 as well. 

Kids and Arthritis

The measles, mumps, and rubella (MMR) vaccination is a live vaccine given at intervals in infancy and childhood. You may have heard that the vaccine leads to temporary arthritis-like symptoms, such as pain and stiffness in joints for a day or two, but such reactions are not common, says Dr. Brown. If they do happen, it’s more likely to be in adult and teen women who have not had the vaccine before. 

What if a child is already living with arthritis? Are vaccines a good idea? If a child has a rheumatic condition but is not taking medications, it is generally safe to give routine vaccines with the recommended vaccine schedule, says Dr. Evelyn Rozenblyum, a pediatric rheumatologist at Sick Kids and Assistant Professor of Pediatrics at the University of Toronto.

However, “if a patient is taking a medication that suppresses the immune system to treat the arthritis, this is when we have to be careful with our vaccine administration. If a child with juvenile idiopathic arthritis is on a biologic medication for example, we recommend they get the live vaccines they need (if they have not yet had them) administered prior to starting these medications if it’s safe to wait to start the biologic medication. Once they are on the biologic medications, we usually suggest deferring live vaccines until they come off and taking the necessary precautions for children who are unvaccinated.” She adds, while the practice in most centres in North America is to wait for live vaccines for children on biologic medications, new evidence is emerging all the time and some centres around the world vaccinate children while they are taking biologic medications, with good results. 

The annual flu vaccine (an inactivated version, not the nasal spray form which contains a live virus) is highly recommended while on DMARD or biologic medication, says Dr. Rozenblyum. When it comes to DMARD medications, again it’s usually recommended to proceed with caution with giving live vaccines to children living with arthritis. However, be sure to discuss options thoroughly with your rheumatologist and family doctor. “With DMARD medications like methotrexate, if the dose is less than 15 mg/m2, it is possible to administer live vaccines (like MMR and varicella) as booster shots.” Still, Dr. Rozenblyum says that “ideally, patients receive live vaccines a few weeks before they start any immune modulating therapies.”

Communication is essential, both for pediatric and adult patients, says Dr. Brown. “I think we need to improve communication between family doctors or primary care providers and the specialists that are involved, because it is sometimes unclear as to who is taking charge of some day-to-day issues. And immunization can sometimes fall through the cracks.”

As with many aspects of arthritis care, there is not a one-size-fits-all approach. Always consult your health care providers to learn which vaccinations are right for you.

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