What is the recommended vaccine schedule for immunocompromised patients with Systemic Lupus Erythematosus (SLE) or Rheumatoid Arthritis (RA) who have never been vaccinated?

Vaccination Schedule for Immunocompromised SLE/RA Patients

Immunocompromised patients with SLE or RA who have never been vaccinated should receive all inactivated vaccines according to standard schedules, but all live-attenuated vaccines are absolutely contraindicated while on immunosuppressive therapy. 1

Critical Principle: Live vs. Inactivated Vaccines

All live vaccines must be avoided in immunocompromised patients due to risk of uncontrolled viral replication and disseminated vaccine-strain infection. 1 The threshold for significant immunosuppression is prednisone ≥20 mg/day for more than 2 weeks, or equivalent immunosuppressive therapy. 1

Recommended Inactivated Vaccines (SAFE - Give These)

High Priority - Strongly Recommended

• Influenza (Injectable): Annual vaccination strongly recommended; consider holding methotrexate for 2 weeks after vaccination to optimize response 1, 2

• Pneumococcal:

  • For patients <65 years on immunosuppression: PCV15 followed by PPSV23 one year later, OR single-dose PCV20 1
  • Strong recommendation for all immunocompromised RA/SLE patients 1, 2

• Recombinant Zoster (Shingrix): Strongly recommended for patients ≥18 years on immunosuppressive therapy; this is NOT the live vaccine and is safe 1, 3

• COVID-19: Recommended for all immunocompromised patients; benefits outweigh theoretical risks 4

• Tdap: Safe and recommended; standard adult schedule 1

Conditionally Recommended

• HPV 9-Valent:

  • Strongly recommended ages 11-26 years 1
  • Conditionally recommended ages 26-45 years if not previously vaccinated, based on shared decision-making 1
  • SLE patients have higher rates of cervical dysplasia and HPV-related cancers, making this particularly important 1

• Hepatitis A & B: Safe to administer; no specific contraindications, though limited data in SLE/RA populations 1

• Meningococcal ACWY: Safe to administer; standard indications apply 1

• Meningococcal B: Safe to administer; standard indications apply 1

• Polio (Injectable IPV): Safe; typically only needed for travel to endemic areas 1

• RSV: Safe to administer if indicated by age/risk factors

Travel/Exposure-Based Vaccines

• Rabies (Inactivated): Safe but may have blunted response; use full 5-dose post-exposure schedule, minimize immunosuppression during series, check titers after completion 1

• Japanese Encephalitis (Inactivated): Safe if travel-indicated

• Tick-Borne Encephalitis (Inactivated): Safe if travel-indicated

CONTRAINDICATED Live Vaccines (DO NOT GIVE)

These vaccines are absolutely contraindicated while on immunosuppressive therapy: 1

• MMR (Measles-Mumps-Rubella): Contraindicated; instead, vaccinate close contacts to create protective cocoon 1

• Varicella (Chickenpox): Contraindicated 1

• Live Zoster (Zostavax): Contraindicated; use recombinant Shingrix instead 1, 3

• Live Influenza (FluMist): Contraindicated; use injectable inactivated vaccine 1

• Yellow Fever: Contraindicated 1

• Oral Typhoid: Contraindicated; use inactivated injectable typhoid if needed 1

• Oral Cholera: Contraindicated 1

• Chikungunya (Live): Contraindicated 1

• Oral Polio (OPV): Contraindicated; use injectable IPV if needed 1

Vaccines Requiring Special Consideration

Vaccinia/Smallpox & Monkeypox

No specific data available for SLE/RA patients. Given these are live vaccines (vaccinia) or closely related, extreme caution warranted. Consult infectious disease specialist if exposure risk exists.

Timing Strategies to Optimize Response

Before Starting Immunosuppression

Ideally, administer all indicated vaccines at least 4 weeks before initiating immunosuppressive therapy. 1 This maximizes immune response.

During Immunosuppression

• Continue vaccination - do not delay needed vaccines, as benefits outweigh risks 1, 2
• Methotrexate: Consider holding for 2 weeks after influenza vaccination 1
• Other immunosuppressants: Continue without interruption for non-live vaccines 1
• High-dose steroids (≥20 mg prednisone daily): Consider deferring non-urgent vaccines until dose reduced, though influenza and pneumococcal should still be given 1

Disease Activity

Give vaccines regardless of disease activity - vaccination does not increase flare risk in the vast majority of studies 1, 5

Critical Pitfalls to Avoid

1. Do not confuse live zoster (Zostavax) with recombinant zoster (Shingrix) - only Shingrix is safe 1, 3

2. Do not withhold inactivated vaccines due to immunosuppression - these patients need protection most 2

3. Do not give live vaccines "just before" starting immunosuppression - need minimum 4 weeks separation 1

4. Do not assume household contacts cannot receive live vaccines - they should be vaccinated to protect the patient 1

5. Do not forget annual influenza vaccination - this is the most commonly missed vaccine 1

Practical Implementation Algorithm

1. Verify immunosuppression status: Prednisone ≥20 mg/day for >2 weeks or equivalent therapy = contraindication to live vaccines 1

2. Prioritize high-risk vaccines first: Influenza, pneumococcal, recombinant zoster, COVID-19 1, 2

3. Complete age-appropriate inactivated vaccines: Tdap, HPV (if age-eligible), hepatitis series 1

4. Add travel/exposure vaccines only as indicated: Rabies, Japanese encephalitis, etc. 1

5. Vaccinate household contacts: Ensure close contacts receive MMR, varicella, and other live vaccines to create protective environment 1

6. Check titers when response uncertain: Particularly for rabies, hepatitis B, and in patients on high-dose immunosuppression 1