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The main message is clear: rheumatic and musculoskeletal diseases (RMDs) shouldn't stand in the way of vaccination.

An expert panel convened by the American College of Rheumatology recently released new guidance for vaccinations in people with RMDs. The report was published simultaneously in and Arthritis & Rheumatology.

The guideline covers nearly all the most common vaccines with the exception of the COVID-19 vaccine. The authors attribute the omission to the rapidly changing nature of the pandemic and related evidence. Recommendations include indications for the vaccines themselves and guidance on managing medications and timing to maximize safety and efficacy.

Anne Bass, MD, is an attending rheumatologist at the Hospital for Special Surgery and a professor of clinical medicine at Weill Cornell Medicine in New York. She also served as the guideline's first author and recently discussed the recommendations with the Reading Room. The exchange has been edited for length and clarity.

What do you see as the overarching message of this guideline?

Bass: The primary principle is to vaccinate and not to miss a vaccination opportunity. What you'll see in the guideline is that there are very few instances where we recommend holding back medications. Clinicians need to know what vaccinations are indicated and give them.

These recommendations are in alignment with existing recommendations from the CDC. The one that is not in alignment is our conditional recommendation that people on immunosuppression between ages 18-65 receive a high-dose or adjuvanted flu vaccine rather than a regular-dose vaccine. That is not something that is recommended by the CDC.

What do you recommend as far as managing immunosuppressive medications in the context of vaccination?

Bass: We recommended a few small medication adjustments.

The first exception is to hold methotrexate for 2 weeks after an influenza vaccine.

The second is for people taking rituximab, which can very much interfere with vaccine response. We recommend deferring non-live attenuated vaccinations (except the flu) until the next time rituximab administration is due, then delaying rituximab for 2 weeks after vaccination.

The other medication question that comes up is what to do if a patient is on steroids. In this case we recommend going ahead with all the vaccines except for patients on high-dose prednisone, which is defined as 20 milligrams or higher. If it's possible to postpone vaccinations until they're on a lower dose of prednisone, they will respond better to the vaccine.

What were the panel's recommendations regarding the safety of live attenuated vaccines?

Bass: In this case, if you're on an immunosuppressant medication, you are obviously at higher risk of developing vaccine-induced illness. The broad recommendation is to hold immunosuppressive medication when you give a patient a live attenuated vaccine. But there are many footnotes and exceptions here.

For example, the literature suggests that conventional DMARDs are probably safe and probably should not be held, especially since for many patients you can't really afford to hold them.

Were there any recommendations that sparked a particularly robust debate among the panel members?

Bass: The one that our patient representatives were especially concerned about was whether to give more than one vaccination on the same day. This is something physicians do all the time and that the CDC recommends, in large part because you don't want to miss any vaccination opportunities.

So we went ahead and recommended it. At the same time, however, the patient panel wanted to make sure clinicians were encouraged to discuss this with their patients, who may nevertheless opt to spread them out.

Key points

• With a few exceptions, it's recommended that people with RMDs on immunosuppressants be vaccinated as normal.
• Hold methotrexate for 2 weeks following flu vaccination.
• Ideally, high-dose prednisone should be tapered before vaccination.
• It is likely safe to continue conventional DMARDs when administering live vaccines.

Read the guideline here and expert commentary on the clinical implications here.