Vaccination Recommendations for Patients with Systemic Lupus Erythematosus

Pneumococcal Vaccination Strategy

The European League Against Rheumatism (EULAR) recommends administering PCV13 first, followed by PPSV23 eight weeks later, then a second PPSV23 dose five years after the first PPSV23, for patients with systemic lupus erythematosus (SLE) on methotrexate with recurrent infections 1, 2
The Centers for Disease Control and Prevention (CDC) and EULAR recommend a sequential vaccination approach, with PCV13 priming followed by PPSV23 boosting, to optimize immune response in immunocompromised patients, although this is primarily based on expert opinion rather than direct comparative trials in SLE 1

The American College of Rheumatology recommends administering annual inactivated influenza vaccine immediately and holding methotrexate for 2 weeks after vaccination if disease activity allows, for patients with SLE on methotrexate with recurrent infections 3, 4
The American College of Rheumatology recommends using only inactivated (intramuscular) influenza vaccine, as live attenuated intranasal vaccine is contraindicated in SLE patients on immunosuppression 2

The American College of Rheumatology recommends assessing disease activity before holding methotrexate for influenza vaccination and vaccinating without holding methotrexate if disease is active or unstable, as some protection is better than none 3, 4
The American College of Rheumatology recommends strongly recommending all vaccinations for patients on prednisone ≤10 mg/day, conditionally recommending all vaccinations for patients on prednisone >10 but <20 mg/day, and conditionally recommending influenza vaccine for patients on prednisone ≥20 mg/day 3, 4

The European League Against Rheumatism (EULAR) notes that fewer than 40% of SLE patients on immunosuppression achieve adequate immune responses to pneumococcal vaccine, but even suboptimal responses provide some protection, and the 13-fold increased risk of invasive pneumococcal disease in SLE patients justifies vaccination despite reduced efficacy 1, 2