What is the recommended pneumococcal vaccine for a 70-year-old patient with rheumatoid arthritis (RA)?

Pneumococcal Vaccination for a 70-Year-Old Patient with Rheumatoid Arthritis

A 70-year-old patient with rheumatoid arthritis should receive a single dose of PCV20 (20-valent pneumococcal conjugate vaccine), which provides complete protection without requiring additional doses. 1, 2

Primary Recommendation

• For adults aged ≥65 years who have never received pneumococcal vaccine, a single dose of PCV20 is the recommended approach and completes the vaccination series. 1, 2
• If PCV20 is unavailable, the alternative is PCV15 followed by PPSV23 at least 1 year later (or 8 weeks later if the patient is on immunosuppressive medications). 1, 2
• After PCV20 administration, no additional pneumococcal vaccines are needed—the series is complete. 1, 3

Special Considerations for Rheumatoid Arthritis Patients

• Patients with rheumatoid arthritis taking immunosuppressive medications are at increased risk of pneumococcal infection and pneumococcal vaccination is strongly recommended. 4
• The 2022 American College of Rheumatology guidelines specifically recommend pneumococcal vaccination for all RA patients on immunosuppressive therapy, regardless of age. 4
• The CDC currently recommends either PCV20 alone or PCV15 followed by PPSV23 for adults with immunocompromising conditions, which includes those on disease-modifying antirheumatic drugs (DMARDs). 2

If Previously Vaccinated

• For patients who previously received only PPSV23, administer PCV20 at least 1 year after the last PPSV23 dose. 1, 2, 3
• For patients who previously received only PCV13, administer PCV20 at least 1 year after the PCV13 dose. 2, 3
• For patients who received both PCV13 and PPSV23, PCV20 may be given ≥5 years after the last pneumococcal vaccine dose based on shared clinical decision-making. 3

Timing Relative to Immunosuppressive Medications

• Ideally, pneumococcal vaccination should be administered at least 2 weeks before starting immunosuppressive medications to ensure optimal immune response. 1
• If the patient is already on methotrexate or other DMARDs, vaccination should still be given without delay—any vaccination is better than no vaccination. 4
• Recent evidence suggests that delaying methotrexate by 1 month after PCV13 vaccination improves immunological responses without compromising disease control, though this applies primarily to newly diagnosed patients initiating therapy. 5

Important Clinical Nuances

• Rituximab-treated patients have notably reduced vaccine responses (25% response rate) compared to patients on other biologics (≥89% response rate), so vaccination timing before rituximab initiation is particularly critical. 6
• Methotrexate-treated patients respond less well to pneumococcal vaccination compared to those not taking methotrexate, reinforcing the importance of vaccinating before initiating therapy when possible. 7
• The presence of interstitial lung disease in RA patients is associated with increased pneumonia risk, making vaccination even more critical in this subgroup. 8

Administration Details

• PCV20 can be administered at the same visit as influenza vaccine or other age-appropriate vaccines at different anatomic sites. 1, 2
• Local reactions (pain, redness, swelling) occur in approximately one-third to one-half of recipients and typically resolve within 48 hours. 1
• Severe reactions are rare, and neurologic complications like Guillain-Barré syndrome have not been causally associated with pneumococcal vaccination. 1

Common Pitfalls to Avoid

• Do not delay vaccination waiting for immunization records—use verbal history to determine prior vaccination status and proceed with appropriate vaccination. 1, 2
• Do not administer PPSV23 after PCV20—once PCV20 is given, the series is complete. 3
• Do not withhold vaccination because the patient is already on immunosuppressive therapy; vaccinate immediately as the benefit outweighs the reduced immunogenicity. 4
• Ensure at least 1 year has passed since any previous PPSV23 dose before administering PCV20. 1, 2, 3

Rationale for PCV20 Over Sequential Vaccination

• Conjugate vaccines like PCV20 have immunologic advantages over PPSV23, including T-cell dependent responses and immunologic memory. 3
• PCV20 provides broader serotype coverage (20 serotypes) compared to the older PCV13 (13 serotypes) while maintaining the immunologic benefits of conjugate technology. 4, 3
• The single-dose PCV20 strategy simplifies the vaccination schedule and improves compliance compared to the two-dose PCV15/PPSV23 regimen. 4, 3