Vaccination for Patients with Rheumatic Diseases in the Era of Biologics

A large proportion of patients with rheumatic disease have an immunocompromised status resulting from disease pathogenesis itself and/or several immunosuppressive drugs including biologics. These conditions are closely related to a higher risk of a variety of infectious diseases. Therefore, a few vaccinations for vaccine-preventable pathogens should be considered in patients with rheumatic disease at the appropriate time. The quadrivalent inactivated influenza and pneumococcal vaccinations, including both 13-valent conjugate and 23-valent polysaccharide vaccines, are strongly recommended in all patients with rheumatic disease. The immunogenicity of influenza and pneumococcal vaccination have generally been demonstrated in patients with rheumatic disease on biologics except for rituximab and abatacept. Vaccines can be administered during therapy with tumor necrosis factor-a antagonists but may be more ideal during a stable or remission status without immunosuppressive therapy. In particular, vaccination should be done at least 6 months after an injection of rituximab as a B-lymphocyte-depleting biologic. Basically, all live-attenuated vaccines should be avoided in highly immunocompromised rheumatic disease patients. The vaccination for herpes zoster (HZ) can be taken carefully according to degree of immunosuppression because the currently available vaccine is only live-attenuated. The newly developed subunit HZ vaccine is promising in immunocompromised patients with rheumatic disease.