If you have rheumatoid arthritis, lupus, psoriatic arthritis, vasculitis, or another rheumatic disease, your medicines may weaken your immune system. That can make some infections more likely and more serious. Vaccines are one of the best ways to protect yourself. The rules for people on these medicines are a little different, though.
This guide follows the CDC adult vaccine schedule and the American College of Rheumatology (ACR) 2022 vaccine guideline.
Which medicines count?
You are considered "immunosuppressed" for vaccine purposes if you take:
Steroids such as prednisone, especially 20 mg a day or more for 2 weeks or longer
Conventional DMARDs such as methotrexate, leflunomide, azathioprine, mycophenolate, tacrolimus, or cyclophosphamide
Biologics such as TNF blockers (adalimumab, etanercept, infliximab), tocilizumab, abatacept, belimumab, anifrolumab, IL-17 or IL-23 blockers, or IL-1 blockers
Rituximab or other B-cell–depleting drugs
JAK inhibitors such as tofacitinib, baricitinib, or upadacitinib
Vaccines you should get
These vaccines are not live, so they are safe while you take your medicines:
Flu shot every year. Get it even if your disease is active, you are on high-dose steroids, or you take rituximab. Do not get the nasal spray flu vaccine (FluMist), because it is live.
Pneumonia (pneumococcal) vaccine. It is recommended for everyone on immunosuppressive medicine, at any adult age. Usually this is one dose of PCV20 or PCV21. Another option is PCV15 followed by a second vaccine (PPSV23) later.
Shingles vaccine (Shingrix). It is recommended for adults 19 and older on immunosuppressive medicine and is given as 2 doses. Getting it before you start treatment is especially important if you will take a JAK inhibitor.
COVID-19 vaccine. Stay up to date. Some people on strong immune-suppressing medicines may need extra doses.
RSV vaccine. Ask your doctor. It is recommended for many immunocompromised adults, but the age rules have been changing.
Tetanus/diphtheria/whooping cough (Tdap/Td). One Tdap dose, then a booster every 10 years.
Hepatitis B (and hepatitis A, if you are at risk). Some people on immune-suppressing medicine are offered a 4-dose hepatitis B schedule.
HPV, if you are in the recommended age range.
Vaccines to avoid while on treatment
Live vaccines contain a weakened germ. In people whose immune systems are suppressed, they can rarely cause infection. The ACR generally advises delaying them while you are on immunosuppressive medicine. Live vaccines include:
MMR (measles, mumps, rubella)
Chickenpox (varicella)
Nasal spray flu vaccine
Yellow fever
Oral typhoid
If you truly need a live vaccine, for example before travel, your doctor may pause your medicine beforehand and keep it paused for 4 weeks afterward. How long to pause beforehand depends on the medicine:
Steroids, methotrexate, azathioprine, leflunomide, mycophenolate: 4 weeks
JAK inhibitors: 1 week
Most biologics (TNF blockers, tocilizumab, abatacept, belimumab, and others): 1 dosing interval
Rituximab: 6 months
Timing tips
Before you start a new medicine: Try to get your vaccines first. This gives the best protection.
Methotrexate: Your doctor may ask you to skip methotrexate for 1- 2 weeks after your flu shot, if your disease is under control. This helps the vaccine work better. Some people have a short flare during the pause.
Rituximab: Rituximab weakens vaccine responses. Most vaccines other than flu work best when given at least 6 months after your last dose. When possible, give them a few weeks before your next infusion.
Steroids: At 20 mg a day of prednisone or more, your doctor may wait until the dose is lower, if that is safe.
Most other medicines (TNF blockers, IL-6 and IL-17 blockers, belimumab, JAK inhibitors) usually don't need to be paused for non-live vaccines.
Common worries
"Will a vaccine make my disease flare?" Most studies show no increase in flares after the flu shot. Data for other vaccines are more limited but reassuring.
Household members should stay up to date on their own vaccines. This helps protect you.
Questions to ask at your next visit
Am I up to date on flu, pneumonia, shingles, COVID-19, and RSV vaccines?
Should I get vaccines before starting a new medicine?
Should I pause methotrexate after my flu shot?
If I take rituximab, when is the best time for my vaccines?
Do I need any vaccines before travel?
Disclaimer: This post is for general education only. It is not personal medical advice and does not replace care from your own healthcare team. Vaccine recommendations change, so check the current CDC schedule and talk with your clinician.
References
Bass AR, Chakravarty E, Akl EA, et al. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis & Rheumatology, 2023.
Kapetanovic MC. Vaccination considerations in autoimmune rheumatic diseases. Nature Reviews Rheumatology, 2026.
Centers for Disease Control and Prevention. Recommended Immunizations for Adults Aged 19 Years or Older. cdc.gov/vaccines.