Which vaccinations should be administered prior to treatment of rheumatoid arthritis (RA) with DMARDs or biologic agents?

Updated: Feb 07, 2020
  • Author: Howard R Smith, MD; Chief Editor: Herbert S Diamond, MD  more...
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Before RA patients start or while they are on nonbiologic DMARD monotherapy (hydroxychloroquine [HCQ], leflunomide, MTX, minocycline, or SSZ), DMARD combination therapy (double [mostly MTX-based] or triple [HCQ, MTX, and SSZ]), or anti-TNF (adalimumab, certolizumab, etanercept, golimumab, or infliximab) or non-TNF (abatacept, rituximab, or tocilizumab) biologic agents, administer all killed vaccines (pneumococcal, intramuscular influenza, and HBV) and human papillomavirus (HPV) recombinant vaccine. [4]

The herpes zoster virus (HZV) live attenuated vaccine should only be administered before RA patients start DMARD monotherapy, combination DMARDs, and anti-TNF or non-TNF biologic agents, as well as in those already receiving DMARD monotherapy or combination DMARDs. This vaccine is not recommended for RA patients already on anti-TNF or non-TNF biologic agents. [4] The ACR recommends consulting the vaccine instructions and the CDC dosing and timing recommendations.

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