Vaccinations in rheumatology

Two things raise the value of vaccination for people with an inflammatory rheumatic condition. First, the condition: inflammatory disease can make some infections more likely or more severe. Then there are the medicines. Most of those that control the condition, the DMARDs, biologics and JAK inhibitors and steroids among them, calm the immune system and leave it less able to fight off infection: only a little on standard tablets such as methotrexate and sulfasalazine, more on biologics, JAK inhibitors and steroids. Prevention you can plan for matters more here than for most people.

Two worries are worth settling first. Having a vaccine does not drain the immune system. What a vaccine does is let the immune system practise on something harmless, so that it responds faster to the genuine infection. Trials lay to rest the fear that a vaccine sets off a flare: among people with rheumatoid arthritis, one study linked none of the vaccines it looked at, the flu, pneumococcal, tetanus and hepatitis vaccines included, to the risk of a flare. It is well established that vaccination cuts the chance of an infection that might derail your treatment.

Nearly every question about vaccines on these medicines comes back to whether the vaccine is live.

Non-live vaccines hold no germ that can multiply. They carry a killed germ, a piece of one, or the instructions for your own cells to make one harmless part of it, so they cannot cause the infection they protect against, even in someone whose immune system is weakened. They can be given on treatment, though the response may be a little smaller. This group takes in the injected flu vaccine, every COVID-19 vaccine, the pneumococcal vaccine and the current shingles vaccine.

Live vaccines hold a weakened living germ. In most people it is too weak to make them ill, but where the immune system is suppressed it can occasionally cause a severe infection. So a live vaccine is generally not given to anyone who has had a biologic in the past 12 months, or who takes, or has taken in the past three months, higher doses of some other immune-suppressing medicines, unless a specialist advises it, and anyone on such treatment has one only after a specialist has weighed it up. The live vaccines in the UK include MMR (measles, mumps and rubella) and MMRV (which adds chickenpox), the nasal spray flu vaccine for children, BCG against tuberculosis, yellow fever, oral typhoid, the chickenpox vaccine and the rotavirus vaccine for babies; the older live shingles vaccine is no longer used routinely.

Shingles shows why the type matters more than the illness. The earlier shingles vaccine was a live one, so it was generally avoided on these medicines; today's is non-live and can be given during treatment. If you are not sure which type a vaccine is, ask before you have it.

Four non-live vaccines cover most of what adults on treatment need.

• Flu, every year, since the virus changes and protection fades; the NHS offers it to people whose immune system is weakened by a treatment, steroids among them.
• COVID-19, when you are offered it; long-term treatment that weakens the immune system, for a condition such as lupus or rheumatoid arthritis, can make you eligible.
• Pneumococcal, against bacteria that can cause pneumonia, meningitis and sepsis; it is offered to people whose immune system is weakened by a treatment, such as steroid medicine.
• Shingles, against a painful return of the chickenpox virus, which becomes more likely as immunity weakens.

National NHS programmes decide who is eligible for each and when, and they change. The shingles programme now reaches younger people: since September 2025, a severely weakened immune system, which some medicines cause, brings an offer of the vaccine from the age of 18, where before it was offered from 50, so many younger people on treatment now qualify. Check your eligibility rather than relying on what applied a few years ago. Your GP surgery or a pharmacy usually gives these vaccines, and your rheumatology team advises on timing and on anything particular to your treatment. Each vaccine's NHS page sets out its side effects, the COVID-19 vaccine's page also saying what to do if you feel unwell afterwards, and the person who gives you the vaccine will go through them with you.

When a vaccine is given can change how well it works, which is a good reason to raise vaccination early.

The best time to catch up on vaccines is before a treatment that damps the immune system begins. That matters most for live vaccines, which may not be possible once treatment has begun, and it gives the other vaccines their best chance of a strong response. Getting ready for a new medicine, a biologic for example, includes a check of your vaccinations; the biologics and JAK inhibitors guide describes that preparation.

Once treatment has started, non-live vaccines remain well worth having. The response may be a little smaller and the protection a little less complete, but some protection beats none, and they stay recommended. Two medicines raise timing questions often enough to mention here, as background, not instructions:

• Rituximab, a biologic that removes some of the immune system's B cells, dulls the response to vaccines for a while, so vaccines around it are timed by the specialist team.
• Methotrexate: holding methotrexate for up to two weeks after a flu or COVID-19 vaccine, if your arthritis allows, can improve the response to the vaccine. That decision belongs to your rheumatology team alone. Never stop or skip your treatment for a vaccine on your own.

Both come down to one idea: small changes of timing, made by the people who know your treatment, can make a vaccine work better without loosening control of your disease.

Many people wonder whether their treatment restricts the vaccines their family can have. Mostly it does not. The people you live with can have their routine vaccinations as normal, most live ones included, and keeping them protected is one way they protect you; the flu vaccine is offered on the NHS to people who live with someone whose immune system is weakened, and a household member who has never had chickenpox may be offered the chickenpox vaccine.

A few cautions apply rather than bans, worth checking with your team:

• Children are offered the nasal spray flu vaccine, which is live. It is usually fine around someone on these medicines; only if someone at home has a very severely weakened immune system should the child have the injected flu vaccine instead.
• A baby who has just had the rotavirus vaccine can pass the weakened virus in their nappies for a few weeks, so wash your hands carefully after changing them.
• After a chickenpox-containing vaccine, such as the MMRV given to young children, the person vaccinated may get a rash of blisters; it should be kept covered, or face-to-face contact with you avoided, until it is dry and crusted.

Apart from that rash, none of this means keeping your distance from family members who have been vaccinated; it means a few short precautions in particular situations, which your team can explain.

Trips abroad take more planning, since a number of travel vaccines are live. The yellow fever vaccine is the main one: it is live, some countries require it for entry, and it is generally avoided when the immune system is weakened. Raise any trip weeks or months before you go, so that your rheumatology team and a travel clinic have time to work out the vaccines you need, the ones that are safe for you, and their timing. If a live travel vaccine cannot be given, an exemption certificate can sometimes be arranged instead, though check before you go whether the country will accept it. Plenty of the jabs a trip calls for carry no living germ at all, and those you can have as usual.

Pregnancy brings its own considerations. MMR, being live, is given before a pregnancy if your medicines allow, and not during one. A baby whose mother took a biological medicine during pregnancy, or while breastfeeding, may not be able to have the rotavirus vaccine, and other live vaccines may be put off until six months of age. The arthritis, autoimmune conditions and pregnancy guide sets out which medicines this applies to.

The companion guide, infections and arthritis medicines, deals with what this one leaves out: what to do when you are unwell or have been close to someone with an infection, and whether medicines are paused during one. If you cannot tell how urgent something is, asking is never a mistake.

A page like this can look like a list of don'ts: a kind of vaccine to steer clear of, dates to juggle and questions to put to your team. Read it the other way round instead. The majority of adult vaccines are non-live, which means you can have them, and on treatment that calms the immune system they do more for you, not less. The one rule that must stick is to ask before any live vaccine. The rest is planning, and planning is what keeps a raised infection risk from shaping your life. In practice, that means catching up on vaccines before starting treatment if you can, keeping up the yearly and routine ones once it is under way, checking before any live vaccine or overseas trip, and letting your team plan the timing. Handled like that, vaccines are among the easiest ways to keep both you and your treatment on track.

What makes a vaccine live or non-live, and why does it matter?

It is the distinction everything else rests on. A non-live vaccine holds no germ that can grow, so it cannot give you the infection it guards against even when the immune system is weakened; these can be given on treatment and are recommended, and they include the flu injection, the COVID-19 vaccines, the pneumococcal vaccine and the shingles vaccine the UK now uses. A live vaccine holds a living but weakened germ, which can occasionally cause a severe infection in someone whose immune system is suppressed, so live vaccines are generally avoided on these medicines and need your specialist's advice before you have one. Among them are MMR, yellow fever, BCG, the oral typhoid vaccine and the nasal spray flu vaccine for children. The infections and arthritis medicines guide is this one's companion, for when you are unwell.

Can a vaccine trigger a flare, or weaken my immune system?

Vaccines do not exhaust the immune system: they give it a safe rehearsal of an infection, so that it can react faster to the real thing. A flare brought on by a vaccine is a common fear, but trials have found otherwise: one study in rheumatoid arthritis saw no link between flares and any of the vaccines it examined, the flu and pneumococcal vaccines among them. What you gain is a smaller chance of an infection that could interrupt your treatment.

Which routine vaccines do I need, and where do I get them?

Four non-live vaccines do most of the work: a flu jab each autumn, COVID-19 vaccination if you are offered it, the pneumococcal vaccine, and the shingles vaccine, which you can have from 18 if a medicine or an illness has severely weakened your immunity. Who qualifies, and when, is set by national NHS programmes that change from time to time, so check rather than assume. Your GP surgery or a pharmacy usually gives them, and your rheumatology team advises on the timing.

Should I pause methotrexate or my biologic when I have a vaccine?

Not on your own. Holding methotrexate for up to two weeks after a flu or COVID-19 vaccine, if your arthritis allows, can improve the response to the vaccine, but whether to do it is your rheumatology team's decision with you, not something to do yourself. Some biologics affect timing too: rituximab dulls the response to vaccines for a while, so vaccines around it are planned with care. Bring vaccination up at a review and let the team set the timing.

Are my family's vaccines a problem for me, and can I have travel jabs?

Your family's vaccines are not usually a problem: the people you live with can have their routine vaccines in the usual way, most live ones included, and keeping them protected helps protect you. A few precautions apply rather than bans: the injected flu vaccine instead of the nasal spray for a child when someone at home has a very severely weakened immune system; hand washing after changing the nappies of a baby who has just had the rotavirus vaccine; and, if someone gets a rash of blisters after a chickenpox-containing vaccine, keeping it covered, or avoiding face-to-face contact, until it is dry and crusted. Your team can say which apply to you. Travel jabs take more planning, because some travel vaccines, yellow fever among them, are live and generally avoided on treatment, so raise it weeks to months before you go.