Vaccinations in Patients with Rheumatic and Musculoskeletal Diseases

Publication Date: January 4, 2023



Key Points

  • Pneumococcal vaccination should be administered to all rheumatic and musculoskeletal diseases (RMDs) patients taking immunosuppressive medication.
  • Recombinant zoster vaccination is recommended for RMD patients >18 years of age taking immunosuppressive medication.
  • Methotrexate should be held for two weeks after influenza vaccination if disease activity allows.
  • Seasonal influenza vaccination should be administered to RMD patients even if their disease is active, they are taking high-dose glucocorticoids, and/or they are on rituximab.
  • In RMD patients on rituximab, vaccines other than influenza should be administered at least 6 months after the last rituximab dose.
  • Infants exposed to tumor necrosis factor (TNF) inhibitors in utero should receive rotavirus vaccination in the first 6 months of life.

Glossary of Terms

Adjuvant: An ingredient used in some vaccines that helps create a stronger immune response in people receiving the vaccine.

Immunogenicity: The ability of a vaccine to elicit an immune response.

Reactogenicity: Typical symptoms (e.g., fever, sore arm, muscle aches) which occur shortly (days) after vaccine administration either at the site of vaccination or systemically.

Seroconversion: Development of antibodies to a pathogen, elicited by a vaccine (or infection), in the blood of an individual who previously did not have detectable antibodies.

Seroprotection: An antibody level capable of protecting against infection or disease.

Titer: Numerical value indicating the level of antibody against a particular pathogen.

Table 1. Guideline Scope


Immunosuppressive medications
(prednisone, methylprednisolone, dexamethasone, hydrocortisone)

Conventional synthetic disease-modifying antirheumatic drugs (DMARDS)
  • Methotrexate
  • Leflunomide
  • Azathioprine
  • Mycophenolate mofetil/mycophenolic acid
  • Calcineurin inhibitors (cyclosporine, tacrolimus, voclosporin)
  • Cyclophosphamide

Biologic DMARDS
  • TNF inhibitors (etanercept, adalimumab, certolizumab, golimumab, infliximab)
  • Interleukin (IL) 6 receptor inhibitors (tocilizumab, sarilumab)
  • IL17 inhibitors (secukinumab, ixekizumab)
  • IL12/23 inhibitors (ustekinumab)
  • IL23 inhibitors (guselkumab, tildrakizumab, risankizumab)
  • IL1 inhibitors (anakinra, canakinumab, rilonacept)
  • T cell co-stimulation inhibitor (CTLA4-Ig/abatacept)
  • B cell depleting agents (rituximab, ocrelizumab, obinutuzumab)
  • BLyS/BAFF inhibitors (belimumab, tabalumab)
  • Interferon alpha receptor inhibitor (anifrolumab)

Targeted synthetic DMARDS
  • Janus kinase ( JAK) inhibitors (tofacitinib, baricitinib, upadacitinib, filgotinib, ruxolitinib)
Non-immunosuppressive medications
  • Hydroxychloroquine
  • Sulfasalazine
  • Colchicine
  • Apremilast
  • Denosumab
  • Intravenous immunoglobulin G (IVIG)


Non-live attenuated
Seasonal influenza
Standard dose, high dose, adjuvanted

  • Polysaccharide (PPSV23)
  • Conjugate (PCV13)b

  • Hemophilus influenza b
  • Hepatitis A
  • Hepatitis B
  • Human papilloma virus (HPV)
  • Inactivated polio
  • Meningococcus B
  • Meningococcus ACWY
  • Tetanus toxoid/Td/Tdap
  • Typhoid (injectable)
  • Zoster sub-unit (Shingrix)
  • Influenza (intranasal)
  • MMR
  • Rotavirus
  • Typhoid (oral)
  • Varicella
  • Yellow fever
  • Zoster (Zostavax)

Rheumatic and musculoskeletal disorders

Inflammatory arthropathies
  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Spondyloarthritis
  • Enthesitis-related arthritis
  • Inflammatory bowel disease-associated arthritis
  • Juvenile idiopathic arthritis
Connective tissue diseases
  • Systemic lupus erythematosus
  • Sjogren’s syndrome
  • Systemic sclerosis
  • Idiopathic inflammatory myopathies
  • Mixed connective tissue disease
  • Undifferentiated connective tissue disease
  • Antiphospholipid antibody syndrome
  • Granulomatosis with polyangiitis
  • Microscopic polyangiitis
  • Eosinophilic granulomatosis with polyangiitis
  • Giant cell arteritis
  • Polyarteritis nodosa
  • Takayasu’s arteritis
  • Cryoglobulinemic vasculitis
  • Relapsing polychondritis
  • Behcet’s disease
  • Kawasaki’s disease
  • IgA vasculitis (Henoch-Schönlein Purpura)
  • Primary central nervous system vasculitis
  • Goodpasture’s syndrome (anti-GBM)
  • Cogan’s syndrome
  • Cutaneous small-vessel vasculitis
  • Rheumatoid vasculitis
  • Urticarial vasculitis
Other inflammatory disorders
  • Sarcoidosis
  • Adult-onset Still’s disease
  • Polymyalgia rheumatica
  • Gout
  • Pseudogout
  • IgG4-related disease
  • Autoinflammatory disorders

a COVID-19 vaccines were not included in this guideline because of the fast-changing face of the pandemic and related literature.

b The recently approved pneumococcal vaccines, PCV15 and PCV20, were not included in the evidence review but are discussed in the text of the guideline. Please refer to current CDC guidelines for specific pneumococcal vaccination strategies.



...iding Principles Indicated vaccinations sh...

.... Summary of Recommendations ...

...indications for patients with RMDs...

...enza vaccinationFor RMD patients aged ≥65...

...umococcal vaccinationFor patients with R...

...inant varicella zoster virus (VZV) vaccination...

...ccination (Gardisil)For patients with RMD ag...

...hold immunosuppressive medication a...

...patients, holding methotrexate for...

...RMD patients, continuing immunosuppressive medic...

...RMD patients, continuing immunosuppres...

...ons in patients on rituximab in order to maximize...

...RMD patients receiving rituximab, adminis...

...ents receiving rituximab, deferring non-live-atten...

...ister non-live attenuated vaccinations to...

...ts who are on the equivalent of pre...

...MD patients who are on the equival...

...s on the equivalent of prednisone ≥20 mg daily,...

...who are on the equivalent of pred...

...fer vaccination in patients with high disease...

...ith RMD, giving non-live attenuated vaccinations i...

...anaging immunosuppressive therapy at...

...RMD patients who are taking immunosuppres...

...RMD patients, holding immunosuppressi...

...ister rotavirus vaccine to infants with...

...tes/infants with second and/or thir...

...or neonates/infants with second and/or third trim...

...her to give multiple vaccinations to RMD patients...

For RMD patients, giving multiple vaccinations...

...ble 3. Immunosuppressive Medication Managem...