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LONDON — For decades, the standard playbook for vaccinating patients with autoimmune inflammatory rheumatic diseases (AIIRD) was defined by hesitation. Fearful that a vaccine might trigger a disease flare or that active inflammation would blunt the immune response, clinicians routinely deferred immunizations until a patient achieved complete disease quiescence.

That paradigm is officially dead, according to experts at the European Alliance of Associations for Rheumatology (EULAR) 2026 Annual Meeting.

“Protection far outweighs hypothetical flare risks,” said Pedro Machado, MD, PhD, professor of rheumatology at University College London, London, England, speaking at the meeting. “Historically, waiting for disease quiescence resulted in suboptimal vaccine coverage and a high, preventable infection burden. Today, infection prevention is a core component of modern rheumatology care, alongside the control of inflammation.”

The shift to a proactive, evidence-based strategy means evaluating vaccination needs immediately upon diagnosis and decoupling vaccine administration from baseline disease activity. However, successfully executing this strategy requires a deep dive into drug-specific kinetics rather than fixed calendar schedules, he explained.

Updated vaccination recommendations, presented at EULAR 2026, also make use of this shift in strategy.

Nonlive vs Live

Nonlive vaccines, including inactivated, subunit, and mRNA platforms, present an excellent safety profile. They can be administered safely at any point, whether at diagnosis, during treatment induction, or throughout maintenance therapy, regardless of the concurrent use of glucocorticoids or disease-modifying antirheumatic drugs (DMARDs).

On the contrary, live-attenuated vaccines remain strictly contraindicated during active immunosuppression. To ensure safety and adequate viral clearance, live vaccines must be administered at least 4 weeks prior to initiating any immunosuppressive regimen, Machado said.

While nonlive vaccines are safe, their efficacy is frequently blunted by specific targeted therapies.

Methotrexate (MTX), for example, is known to cause moderate attenuation of vaccine responses. Pausing MTX for 1-2 weeks immediately following vaccination significantly increases seroconversion rates across multiple trials evaluating influenza, SARS-CoV-2, and pneumococcal vaccines. Machado said that while these data rely on surrogate immunogenicity markers rather than hard clinical endpoints, the strategy carries a very manageable, transient risk for mild flare.

JAK inhibitors and abatacept significantly blunt humoral responses, particularly against the recombinant zoster vaccine (RZV). Because patients with rheumatoid arthritis or systemic lupus erythematosus (SLE) already carry a 1.5- to 2.0-fold increased risk for herpes zoster, which spikes drastically upon starting a JAK inhibitor, prioritizing RZV completion before drug initiation is highly recommended.

With B-cell depleting therapies such as rituximab, the common clinical practice of administering vaccines at a fixed 6-month interval after a rituximab infusion is fundamentally flawed, Machado said. Because B-cell depletion profoundly dampens humoral responses, vaccine timing should ideally be driven by measured biological B-cell repopulation kinetics. In the absence of accessible cell-count tracking, the best clinical surrogate is vaccinating immediately before a patient’s next scheduled maintenance dose.

In Utero Exposure and the Household Ring

Due to active placental transfer of maternal immunoglobulin G1 (IgG1) biologics during late pregnancy, infants born to mothers on these therapies carry detectable drug levels at birth. This means that live vaccines are not safe during the first 6 months of life; thus, standard live immunizations, such as BCG, must be delayed. Exceptions include certolizumab pegol, which does not cross the placenta, and oral rotavirus vaccines, which recent data suggest can bse safely administered on schedule despite antenatal TNF-inhibitor exposure.

For highly immunocompromised patients, building a household shield is very important. All immunocompetent contacts in the patient’s immediate environment should be up to date on their immunizations. However, Machado reminded that the live oral polio vaccine remains strictly contraindicated for household contacts due to viral shedding risks, and immunosuppressed individuals should avoid handling the diapers of infants given the oral rotavirus vaccine for 4 weeks post-vaccination.

Gaps and Challenges

Despite robust consensus guidelines, a glaring gap persists between evidence and clinical execution. “There is a need for more effective delivery strategies in routine rheumatology,” Machado said.

Anja Strangfeld, MD, a professor of epidemiology at the German Rheumatology Research Center in Berlin, Germany, who was chairing the session, commented that the primary barrier to high vaccine coverage is rarely patient hesitancy, but rather an omission gap in daily clinical workflows.

“Vaccination audits must be hardcoded into routine referral letters and clinical checklists exactly like disease activity scoring,” Machado responded. “If we do not explicitly review it at diagnosis, the window of opportunity is frequently lost.”

Speaking to Medscape Medical News, Strangfeld welcomed the updated EULAR recommendations, saying they provide clinicians with an essential, clear roadmap that completely demystifies the timing and safety of vaccines under modern therapeutic regimens.

Updated EULAR Vaccination Recommendations

EULAR released updated clinical recommendations on vaccination, presented by Ori Elkayam, MD, head of the rheumatology department at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, at EULAR 2026. The updated framework shifts the core clinical focus from a patient’s baseline disease activity to the precise biological kinetics and timing of their immunomodulatory therapies.

The Overarching Principles

• Shared decision-making: Vaccination strategies must be individualized and developed collaboratively between the rheumatology team, primary care physicians, and the patient.
• Mandatory annual audits: A formal assessment of the patient’s vaccination status must be performed and documented at least once a year by the rheumatology team.
• Timing over quiescence: Vaccines should ideally be administered prior to initiating immunosuppressive therapy. Crucially, nonlive vaccines should never be delayed out of fear of a disease flare or active inflammation.
• The household shield: Immediate family members and close household contacts should be fully vaccinated to build a protective ring around the patient, adhering strictly to live-vaccine restrictions where shedding hazards exist.

Summary of Key Vaccine Recommendations

• Influenza: Strongly recommended annually for all patients with AIIRD. Clinicians should consider high-dose or adjuvanted formulations for patients on anti-CD20 therapies (eg, rituximab) or high-dose glucocorticoids to overcome blunted immune responses.
• Pneumococcal: Indicated for all adult patients with AIIRD. The updated guidelines favor a sequential conjugate/polysaccharide regimen (eg, PCV15 or PCV20 followed by PPSV23) or a conjugate-only schedule depending on regional availability.
• COVID: Continuous seasonal or booster dosing should be administered in alignment with national high-risk cohort protocols.
• Herpes zoster (Shingles): The nonlive RZV is strongly recommended for all patients with AIIRD aged 50 years or older. Critically, it should now be considered for high-risk patients aged 18-49 years, particularly those starting JAK inhibitors or broad biologic DMARD therapies.
• Human papillomavirus (HPV): Recommended for all patients with AIIRD up to age 26 (and via shared decision-making up to age 45), with a strong emphasis on patients with SLE due to their elevated risk for cervical dysplasia.
• Hepatitis B: Screening is mandatory before starting biologics or targeted synthetic DMARDs. Nonimmune patients should be vaccinated, and postvaccination anti-HBs serology must be checked; if protective titers drop < 10 mIU/mL, a booster series is required.
• Travel Vaccines: Nonlive travel vaccines (such as hepatitis A, typhoid injection, or meningococcal) are entirely safe. Live travel platforms (like yellow fever or oral typhoid) remain generally contraindicated during active immunosuppression unless the patient meets strict low-level therapy criteria and faces unavoidable endemic exposure.

Immunosuppressive Drug Modulations

• MTX hold: Pausing MTX for 2 weeks immediately following seasonal influenza or pneumococcal vaccination is recommended to optimize seroconversion, provided the patient’s flare risk is clinically manageable.
• B-Cell depletion (rituximab): Nonlive vaccines should be timed at least 6 months after the last rituximab infusion, and ideally 4 weeks before the next dose, to align with early B-cell repopulation kinetics.
• Live vaccine safety margin: All required live-attenuated vaccines must be completed a minimum of 4 weeks prior to the initiation of any biologic or targeted synthetic DMARD.
• Neonatal live-vaccine exclusion: Infants exposed in utero to maternal IgG1 biologics during the second or third trimesters should not receive live vaccines (eg, BCG or rotavirus) for the first 6 months of life. This restriction does not apply to certolizumab pegol due to its lack of placental transfer.

Machado, Strangfeld, and Elkayam reported having no relevant financial relationships.

Manuela Callari is a freelance science journalist specializing in human and planetary health. Her work has been published in The Medical Republic, Rare Disease Advisor, New Scientist, The Guardian, MIT Technology Review, and others.