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Reducing Risk of Infection in People With Rheumatoid Arthritis

Adapted from a presentation to the HSS Early RA Support and Education Program

Infections are a serious concern for people with autoimmune inflammatory disease like rheumatoid arthritis. Learn what you need to know to lower your risk of developing an infection while managing your rheumatoid arthritis.

Does rheumatoid arthritis increase risk of infection?

People with rheumatic diseases like rheumatoid arthritis (RA) are often at increased risk of infections because they may take immunosuppressive drugs to treat their disease. Immunosuppression, or the artificially reduced function of the immune system, decreases the inflammation associated with rheumatic conditions. The downside is that it also decreases your body’s immune functions.

You may hear the term “iatrogenic” as infection risk relates to you. This refers to when a medical treatment causes an unintended outcome, such as a weakened immune system due to treatment of RA.

Can my rheumatoid arthritis medication increase my risk of infection?

Different medications you take may have an impact on your risk for infection. If you have RA, you may be taking corticosteroids, disease modifying antirheumatic drugs (DMARDs), such as methotrexate, leflunomide (Arava), azathioprine (Imuran), and cyclosporine (also sometimes spelled cyclosporin and ciclosporin). Anti-TNF and other biologic agents can make you vulnerable to systemic infections such as bacterial sepsis, tuberculosis (TB), fungal infections, and viral reactivations such as varicella zoster (shingles) and hepatitis B.

Studies show RA increased the rate of infection for people taking adalimumab (Humira) is 4.65 per 100 (/) years.

Anti-TNFs increase the relative risk of infection, especially in the first year of use. As time passes, the risk decreases. Simple things, such as dental cleanings, are some of the best things you can do prevent infection. In order to reduce the risk of harm, therapeutic biologic agents can be put on hold both when serious infections occur, as well as before and after surgery. There are also tests to detect TB, and ways to reduce risk of infection in prosthetic (artificial) joints, such as hip or knee replacement implants.

There are many ways to prevent and treat infections, and your rheumatologist can help you make informed choices.

Ways to reduce the risk of common health threats

  • Be proactive.
  • Talk to your doctor about vaccines.
  • Practice good hygiene.

How do vaccines work?

Vaccines are made in both live and killed versions. Live vaccines (also known as “attenuated” vaccines) use a weak form of a disease-causing germ, while killed vaccines (also known as “inactivated” vaccines) use an inactive form of a disease-causing germ. Live vaccines are not recommended, because you cannot control the immune system, and when your immune system is not able to effectively protect you from live viruses or bacteria, they can multiply in your body.

A live vaccine immunizes you by giving you a small amount of the agent (virus or bacterium), which is not optimal for a person with RA. Killed vaccines are safe and effective. In fact, the American College of Rheumatology highly recommends the pneumococcal, influenza, and hepatitis B vaccines for patients with rheumatic diseases.

There are vaccines for Tdap (tetanus, diphtheria and pertussis), pneumococcus, influenza (flu), hepatitis B, and the varicella zoster (“shingles”) virus. There is the Salk vaccine for polio (which consists of a killed virus). In addition, the Johnson & Johnson, Moderna and Pfizer vaccines for the SARS-CoV-2 virus that causes COVID-19 in humans do not contain live virus cells.

Can I get a vaccine if I have rheumatoid arthritis?

People with RA should not take live vaccines, only killed vaccines. For Yellow Fever there is only a live vaccine. However, while there are many live vaccines, there are often killed versions that can be given more safely. Typhoid and salmonella typhoid vaccines are also available, but they should not be taken when your immune system is not strong. Of note, there’s no better way to prevent respiratory infections than to receive influenza and pneumococcal vaccines.

Always discuss vaccinations with your doctor since they are aware of helpful guidelines regarding the best options for you. Learn more about the following vaccines below:

Show pneumococcus the door

Pneumococcal vaccines can prevent some cases of pneumonia and other diseases caused by the bacteria streptococcus pneumoniae. Two very effective pneumococcal vaccinations are Pneumovax 23 (PPSV23) and Prevnar13. Pneumovax is effective against 23 types of pneumococcal bacteria.

Prevnar is only effective against 13, but more effective against those 13 because it has been made to produce more potent immunity.

The Centers for Disease Control and Prevention (CDC) encourages everyone to receive a pneumococcal vaccination. Specifically, the CDC recommends it for all children under two years old, all adults 65 years or older, and people of ages in between who have certain medical conditions.

Talk to your doctor about timing of these vaccines since they should not be given together. Your doctor will guide you as to which vaccine to get and when, based, on your medical history and age.

Do believe the hype about the flu

Why is influenza such a scary thing? The flu, which affects the respiratory tract, is different from other viruses. It causes major inflammation of larynx, trachea and bronchi. If you have underlying pulmonary disease, influenza can make that worse. Serious complications of the flu are myositis (inflammation of the muscles), or myocarditis (inflammation of the heart). The virus can also go directly to your lung and give you viral pneumonia. When bacteria take advantage of the viral-infected lung, this becomes a super infection, in which there is one infection on top of another. Super-infection pneumonia is one of the most dangerous types of pneumonia.

It’s best to prevent the whole process to begin with.

The best protection against the flu is the influenza vaccine. When you have RA, you want to avoid the live form of flu vaccine. Although the vaccines only work 60% to 65% of the time, they are far better than nothing.

Keep in mind, the vaccine lasts six months and flu can start earlier than November. Flu season can last into May, and every year is unpredictable.

Types of influenza vaccines

  • quadrivalent – protects against four strains of flu virus
  • trivalent – protects against three strains of flu virus
  • intradermal – (available as quadrivalent) injected into the skin
  • intramuscular – injected into the muscle
  • adjuvant – (formerly trivalent, now quadrivalent) promotes enhanced response (given only to those 65 or older)
  • high-dose – (formerly trivalent, now quadrivalent) promotes enhanced response (given only to those 65 or older)
  • recombinant – 100% egg free

CDC does not prefer any of these types over the others. They recommend only that you discuss options with your doctor and get vaccinated for influenza.

Who are the target groups for the flu vaccine?

  • pregnant women
  • adults over 65 years old
  • healthcare and emergency services personnel
  • children six months to four years old
  • people with medical conditions which place them at higher risk for complications of influenza
  • persons providing care for infants less than six months old

What if I get the flu anyway?

These medication options can lessen the severity of the flu if taken early when symptoms first arise.

  • oseltamivir (Tamiflu) − pills/capsules
  • zanamivir (Relenza) − inhaler
  • baloxavir marboxil (Xofluza) − pills/capsules
  • Peramivir (Rapivap) − intravenous

Why hygiene matters

The flu is very contagious and transmitted by saliva and nasal secretions. Flu even lives on dry surfaces for days or weeks, and then without thinking you touch your eyes or nose.

Cough and sneeze particles, unshielded, can travel as much as three feet. Turn your back away if you can. Also, don’t become a source of contagion for others – cough into your elbow, have tissues at the ready for a sneeze.

Along with covering your mouth and nose, the best practice to keep germs at bay is hand washing.

Whenever possible, avoid contact with infected people

Possible side effects of the flu vaccine

When you get the vaccine, you can get fever or feel malaise (a general sense of weariness or illness). If you take an aspirin or acetaminophen (Tylenol) these symptoms should disappear quickly. If symptoms persist for more than 48 hours – it’s not likely due to the vaccine, call your doctor.

Other less common side effects of the influenza vaccine include Guillain-Barré (a rare syndrome in which the immune system attacks your nerves) and allergy such as hives.

While most vaccines are made from eggs, you would have to be severely allergic to have a bad reaction. As always, review with your doctor.

Hepatitis B

If you have hepatitis B that hasn't been treated, you should be concerned when you take anti-TNF medications, and you must discuss this with your doctor. There is very effective therapy for Hepatitis B and there is an excellent vaccine available to prevent Hepatitis B.

Shingles (herpes zoster; varicella zoster)

Herpes zoster (“shingles”) is chicken pox as a reactivated infection later in life. The varicella zoster virus that causes chicken pox lives in your nerves forever. In adults, the virus becomes more severe, and metabolic and physical stresses make it multiply quickly to reappear as shingles. The skin surface rash associated with shingles reflects an infection of the nerve beneath the skin. This causes neuritis (inflammation of the nerve) and neuralgia (pain in the nerve). The reactivated virus can cause post-herpetic neuralgia, a more severe form of nerve pain, may last weeks or months and can be disabling.

As we age, our immune system gets weaker every year, so there’s value in getting protection.

Similar to others, you cannot take this as live vaccine., but there is a newer non-live vaccine (Shingrix) available which you can discuss with your doctor.

The Shingrix vaccine, a herpes zoster vaccine (for shingles)

  • For adults over 50 years old
  • It is a two-dose vaccination process
  • Highly effective. Decreases shingles risk by 85% to 98%.
  • Post herpetic neuralgia (nerve pain caused by the varicella zoster virus) is also reduced by Shingrix vaccination
  • 89% to 91% who come down with the virus won’t come down with post-herpetic neuralgia.

You should discuss the Shingrix vaccine with your doctor before receiving it.

Should I get the COVID-19 vaccine if I have rheumatoid arthritis?

For most patients with rheumatoid arthritis (and other autoimmune diseases), the COVID-19 vaccine is recommended. However, because each patient may be affected differently by their disease, you should discuss this question with your rheumatologist and healthcare team. The Centers for Disease Control and Prevention continually update their guidance on COVID-19 vaccines.

This article is based on a presentation by Dr. Brause to the HSS Early RA Support and Education Program.


Barry D. Brause, MD

Attending Physician, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College

Laura Jasphy, Ed.D
Senior Clinical Social Worker, Hospital for Special Surgery

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