Yes, flu shots. The flu vaccine, which became available in the Fall, is considered your best protection against the flu. The Centers for Disease Control and Prevention (CDC) recommends getting your flu shot by the end of October, but for as long as there are circulating flu viruses, you can still benefit from getting a flu shot. Peak flu season is usually December through February, but it is possible for flu activity to linger into May. RELATED: Why You Don’t Want to Get the Flu When You Have Rheumatoid Arthritis The American College of Rheumatology now recommends that all people with RA receive adjuvanted flu vaccines, or high-dose flu vaccines, that allow the body to have a heightened immune response to the flu germ. Typically, these high dose flu shots are recommended for people aged 65 or older, but this year they are recommended for all people, of any age, who live with RA as well as lupus and other rheumatic diseases who are taking immunosuppressant drugs. RELATED: Why You Don’t Want to Get the Flu When You Have Rheumatoid Arthritis Historically, each year the CDC has generated estimates of the number of illnesses, medical visits, hospitalizations and deaths that happen during a flu season (i.e., the annual burden of flu). To produce these estimates, CDC uses a mathematical model based partly on the number of people that are hospitalized with flu in their hospitalization surveillance network. During the 2020-2021 season, though, because we are in the midst of the COVID-19 pandemic, the flu season was atypical. The low numbers of people hospitalized with influenza was too low to yield stable burden estimates. Despite that fact, flu prevention and flu vaccination is as essential as ever – especially for those in high-risk groups.
Why People With Rheumatoid Arthritis Should Not Ignore the Urgency of Flu Prevention
Suffice to say, the flu is serious stuff. It can’t be ignored. Add to that the fact that people with rheumatoid arthritis (RA) have an increased risk of infectious disease-related morbidity and mortality and may have up to twice the risk of acquiring a serious infection compared with people in the general population. The increased risk of infection associated with RA is attributed, in part, to the autoimmune disease itself, and also to the immunosuppressant medication used by many RA patients. Despite the importance of getting an annual flu shot for the aforementioned reasons, the flu vaccination rate is just 25.3 percent among people with inflammatory rheumatic diseases, according to research published in the journal Vaccine. While there seem to be several reasons that 3 out of 4 people with RA steer clear of the flu shot, a recommendation from your doctor is the best predictor that you will follow through and get the shot, according to the researchers. Vaccine hesitancy with regard to the flu vaccine was analyzed in a research paper published in September 2020 in Human Vaccines and Immunotherapeutics. Responses from questionnaires given to rheumatic disease patients revealed concerns about safety and effectiveness of flu vaccines, as well as a concern that it would make their RA worse.
The answer is “Yes” to all five questions. The existence of COVID-19 does not negate or interfere with usual precautions or measures taken to prevent the flu.
It’s a Myth That People Taking Biologics or DMARDs for RA Can’t Get a Flu Shot
It is true that people with RA who are treated with biologics or disease-modifying anti-rheumatic drugs (DMARDs) cannot get a “live” flu vaccine, but they can be given an inactivated or dead flu vaccine. A common misconception about flu shots given to those treated with biologic drugs or DMARDs is that the immunosuppressant drugs render the flu vaccine ineffective. Not true. In fact, according to research published in the journal Current Rheumatology Reports, people with RA who are treated with methotrexate or TNF inhibitors — such as Enbrel (etanercept), Remicade (infliximab), Humira (adalimumab) — have an acceptable response to the flu vaccine, although it is a lower response than what is achievable by healthy people. Treatment with Actemra (tocilizumab) also is associated with an adequate response to flu vaccine. A reduced response to the flu vaccine was attributed to treatment with Orencia (abatacept) and a severely reduced response to the flu vaccine was linked to treatment with Rituxan (rituximab). Keep in mind, a lower response than is achievable by healthy people is not synonymous with an inadequate response or no response. There is still a protective effect which makes it essential for flu prevention.
Optimal Timing for Administering Flu Vaccine to People With RA
The American College of Rheumatology (ACR) recommendations (PDF) for RA state that the best time for administering vaccines is prior to starting a biologic drug or a DMARD. That said, in most circumstances once you are using a biologic drug or DMARD, you are not excluded from the beneficial effects of vaccination. There is sufficient protective effect even if it is not the full effect that can be obtained by healthy people. Some measure of prevention is better than none.
Consider Getting the High-Dose Flu Vaccine to Boost the Immune Response
There is a high-dose flu vaccine available for people who are age 65 and older. While it has been recognized for years that people who are 65 and older are at greater risk for complications from the flu because immune defenses become weaker with age, a higher-dose flu vaccine became available in the United States in 2009. The high-dose flu vaccine has 4 times the amount of antigen as the regular flu shot, provoking higher antibody production and a stronger immune response. According to research published in The New England Journal of Medicine, clinical trials showed that study participants who received the high-dose vaccine had 24 percent fewer flu infections compared with those who received the regular dose vaccine.
Data on High-Dose Flu Vaccine in People With RA Is Promising
At the 2018 annual meeting of the ACR, research findings were presented after the high-dose flu vaccine was evaluated in RA patients. Annual flu vaccines are recommended for people with RA, but since it is known their response is not optimal, a group of researchers from Montreal set out to determine if the high-dose flu vaccine could boost the antibody production against the flu in people with RA. They compared a high-dose trivalent inactivated influenza vaccine (HD-TIV) to a standard-dose quadrivalent inactivated influenza vaccine in a total of 279 adults with seropositive RA. It was found that the high-dose vaccine did safely, consistently, and substantially boost the response in seropositive RA patients. In November 2019, The Lancet Rheumatology published the study results, the first evidence to support the use of the HD-TIV in RA patients.
Ask Your Doctor About a High-Dose Flu Shot
In May 2020, the journal Vaccine published results from a study which evaluated high-dose trivalent flu vaccine in RA patients treated with TNF-alpha drugs. TNF-alpha therapy in people with RA did not appear to influence the immunogenicity of either standard dose or high-dose flu vaccine. Antibody responses of RA patients receiving high-dose was greater than for standard dose. The difference was small and larger studies are needed to validate the conclusions.
Take a Methotrexate Holiday to Boost Efficacy of Flu Vaccine
Findings published in the journal Annals of the Rheumatic Diseases indicate that people with RA who routinely take methotrexate can boost the immune response obtained with the flu shot by stopping methotrexate for two weeks after getting the vaccine. Study results indicated that 75.5 percent of study participants who temporarily stopped methotrexate for two weeks had a satisfactory response to the flu vaccine compared with 54.5 percent of those who did not temporarily stop taking methotrexate. It was also determined that disease activity did not significantly increase in the patients who stopped methotrexate for two weeks. The same can’t be said of stopping methotrexate for four weeks. Study results suggest that stopping methotrexate for four weeks increased disease activity in RA, so that is not the recommendation. Discuss with your doctor the best options for you as an individual. Scott J. Zashin, MD, a rheumatologist in Dallas, commented: “If possible, it is now recommended by some doctors to stay off of methotrexate for one to two weeks after the flu shot to improve efficacy. Methotrexate is out of the blood stream in 48 hours, although its effect in tissues lasts longer.”
The Takeaway on Flu Protection for People Living With RA
The flu vaccine is still considered the best preventative measure you can take against the flu. It is even more important for people with RA because of their increased risk of infection. Be mindful of what you can do to boost the effectiveness of the flu shot in your specific circumstance. Three things you must remember and should discuss with your doctor:
COVID-19 precautions do not eliminate the need for flu prevention measures and flu vaccination.The high-dose flu vaccine may be a better option for people with RA.Stopping methotrexate for one to two weeks after receiving a flu vaccine can help boost your response.
