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Top 5 Things Rheumatologists Should Know about Vaccines

May 06, 2015 12:00 am

Rheumatologists should have a working knowledge on what vaccinations their patients need. The top 5 things rheumatologists should know about vaccines are:

1.Live vaccines can be given to patients despite some degree of immunosuppression.

The ACIP suggested that live vaccines can be safely administered in patients receiving prednisone <20 mg/day, MTX < 0.4 mg/kg/week (this amounts to about 25 mg/week in anyone > 136 lbs), azathioprine 3 mg/kg/day, or 6-MP < 1.5 mg/kg/day. There are ongoing studies examining if live vaccines (e.g, shingles vaccine) can safely be given to patients on biologics as retrospective reviews suggest no harm.  An inactivated shingles vaccine is in the works.

2.You can give 1 live with multiple inactivated vaccines on the same day.

Don’t let the pharmacist deter you or your patients from getting the shingles, pneumonia and flu vaccines the same day if this is what needs to happen to get the patient vaccinated.  The exception to the one-day multiple vaccination is if 2 live vaccines are to be administered (e.g, MMR and shingles)—they need to be given at least 28 days apart.

3.Don’t just give 1 pneumococcal vaccine and think you’re done!

The ACIP recommends patients > 65 y.o. receive both the 23 valent (PPSV23) and the 13 valent (PCV13) pneumococcal vaccines. The timing is crucial.  If you give the PPSV23 first, you must wait at least a year to administer the PCV13; however, if you administer the PCV13, you only have to wait at least 2 months to administer the PPSV23. You need to repeat once the PPSV23 -- 5 years after the last PPSV23 was given. Of note, the PCV13 is approved for patients > 50 y.o.

4.Household contacts of the immunosuppressed person can still receive live vaccines.

This includes shingles, MMR, and rotavirus. If a blistering rash occurs on the household contact at the site of the shingles vaccine, the site should be covered and avoided by the immunosuppressed person. If an infant received the rotavirus vaccine, frequent handwashing after diaper duty is recommended.

5.The only contraindication to receiving the flu vaccine is anaphylaxis.

Patients with previous vaccine-related adverse events (e.g, Guillain-Barre syndrome), can still receive the flu vaccine, recurrent reactions are rare. Patients who have hives as an egg allergy can still receive the flu vaccine, note that there is now an “egg-free” flu vaccine called Flublok


Live Vaccines

Inactivated Vaccines

  • Mumps Measles Rubella (MMR)
  • Varicella Zoster vaccine (VZV)
  • Live attenuated influenza vaccine (LAIV)
  • Herpes Zoster Vaccine (HZV)
  • Yellow fever
  • Oral typhoid
  • Bacille Calmette-Guérin (BCG)
  • Rotavirus (RV)
  • Adenovirus type 4, 7 , oral
  • Smallpox (Vaccinia)
  • Tetanus diphtheria/acellular pertussis (Td/Tdap)
  • Hepatitis A Vaccine (HAV)
  • Hepatitis B Vaccine (HBV)
  • Human Papilloma Virus (HPV)
  • Influenza A/B/H1N1 (TIV)
  • Meningococcal vaccine (MCV)
  • Pneumococcal vaccine (PCV)
  • Inactivated polio vaccine (IPV)
  • Rabies Vaccine
  • Typhoid polysaccharide vaccine


JAMA. 2012 Jul 4;308(1):43-9. doi: 10.1001/jama.2012.7304.

Author's note: With the recent measles outbreak in the U.S., 62% of those infected were adults. This brings to light that our patients, who are immunocompromised and at particularly high risk for complications, may require additional vaccinations with this live, attenuated vaccine. The CDC recommends re-vaccinating those older than 20 y.o. but born after 1957 who have not received 2 doses of live measles/MMR vaccines or have no evidence of immunity to these viruses.  



The author has no conflicts of interest to disclose related to this subject

Kathryn Dao, MD, FACP, FACR, is a rheumatologist based in Dallas  She is the president of Rheum101, an educational forum teaching rheumatology to whomever wants to learn. Her interests include rheumatoid arthritis, systemic lupus erythematosus, drug safety, and pregnancy in rheumatic diseases. Follow her on twitter @KDAO2011