The ACR recently released its first guideline focused on vaccination in adult and pediatric patients with rheumatic and musculoskeletal diseases.1 The guideline recommends modifications to certain vaccine and medication schedules to increase immunogenicity and ensure patient safety, while encouraging providers not to miss vaccination opportunities.
Patients with rheumatic conditions who are on immunosuppressive medications are at greater risk of vaccine-preventable infections and poor outcomes from infections than healthy individuals, making immunization a key protective action. Providers must weigh the risks of disease flare following medication withdrawal against the risks of poor immunogenic protection.
Anne R. Bass, MD, professor of clinical medicine at Weill Cornell Medicine and the Hospital for Special Surgery, New York City, and the guideline’s lead author, notes, “I think one of the goals of the guideline is that rheumatologists should be a little bit more proactive and take more ownership [of vaccination] because internists are not going to know the fine details of how to manage medications.”
Although rheumatologists may administer only a limited number of vaccines in their clinic, such as for influenza, Dr. Bass says she has become more involved in her patients’ vaccinations since many vaccines became available in pharmacies, at least in some states. And in some cases, patients see their rheumatologists more than any other medical provider.
The guideline repeatedly emphasizes the importance of getting vaccinations accomplished when opportunities arise. Karen B. Onel, MD, a professor of clinical pediatrics also at Weill Cornell Medicine and chief of pediatric rheumatology at the Hospital for Special Surgery, says, “Sometimes when people come to see us, we have to take the opportunity to vaccinate, even if it’s not perfect, especially for something like the seasonal flu.”
Note: This guideline does not contain recommendations on COVID-19 vaccines, currently provided elsewhere.2 Dr. Bass, who also served on the ACR COVID-19 Vaccine Task Force, explains the recommendations provided in the COVID vaccination guidance document differ somewhat; this is partly because building immunogenicity was so important in a population initially completely naive to the SARS-CoV-2 virus.
As with previous recent ACR guidelines, this one follows the GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation), including an evaluation of specific PICO questions (clinical population, intervention, comparator, outcomes) used to develop the strong or conditional recommendations. The following is a brief discussion of some of the key points discussed there in full.1