Pre-Rituximab Vaccination Protocol for Rheumatoid Arthritis Patients
Essential Vaccinations Before Rituximab Initiation
- The American College of Rheumatology recommends administering pneumococcal and influenza vaccines at least 2 weeks prior to the first rituximab infusion to maximize immune response, as rituximab severely impairs vaccine responses for up to 6 months after treatment 1, 2
- Administer 23-valent pneumococcal polysaccharide vaccine (PPV23) 8 weeks after 13-valent pneumococcal conjugate vaccine (PCV13), with PPV23 dosing being a single 0.5 mL intramuscular or subcutaneous injection 3, 4
- Complete both pneumococcal vaccines before rituximab whenever possible, with the European League Against Rheumatism recommending this approach 2, 3
- Administer seasonal inactivated influenza vaccine annually, with dosing being a single 0.5 mL intramuscular injection of quadrivalent inactivated vaccine 1, 2, 3
- Ensure tetanus toxoid vaccination is up to date, with the Centers for Disease Control and Prevention recommending a single 0.5 mL intramuscular injection of Tdap if not received in the past 10 years 3, 4
Additional Vaccinations to Consider
- If patient lacks documented immunity, administer MMR booster (0.5 mL subcutaneous) at least 4 weeks before rituximab, as recommended by the American Academy of Pediatrics 4
- Use inactivated typhoid vaccine (Vi polysaccharide), with dosing being a single 0.5 mL intramuscular injection, repeat every 3 years, as recommended by the World Health Organization 4
Critical Timing Algorithm
- Optimal scenario: administer PCV13, influenza, Tdap, and hepatitis B vaccines 8-12 weeks before rituximab, with live vaccines given 4 weeks before rituximab if needed, and PPV23 and hepatitis B dose 2 given 8 weeks after initial vaccines 1, 2, 6
- Suboptimal but acceptable scenario: give PCV13, influenza, and Tdap simultaneously 2-4 weeks before rituximab, and plan PPV23 for next rituximab cycle 1, 2
Contraindicated Vaccines on Rituximab
- Never administer live vaccines once rituximab is started or within 6 months after last dose, including MMR, varicella, and live attenuated influenza vaccine, as recommended by the Infectious Diseases Society of America 5