Contraindicated Vaccines in Patients on Rituximab

Live-Attenuated Vaccines to Avoid

• The American College of Rheumatology recommends avoiding measles, mumps, rubella (MMR) vaccine in patients on rituximab due to the risk of inducing infection by vaccination 2, 3
• The American Thoracic Society recommends avoiding varicella zoster virus (VZV) vaccine (live version) in patients on rituximab 4
• The American College of Rheumatology recommends avoiding yellow fever vaccine in patients on rituximab due to the risk of inducing infection by vaccination 1, 5
• The American College of Rheumatology recommends avoiding oral polio vaccine in patients on rituximab due to the risk of inducing infection by vaccination 1
• The European League Against Rheumatism recommends avoiding BCG vaccine in patients on rituximab 6
• The American College of Rheumatology recommends avoiding live attenuated influenza vaccine in patients on rituximab due to the risk of inducing infection by vaccination 1

Mechanism of Risk

• Rituximab impairs immune responses for up to 6 months after treatment, increasing the theoretical risk of developing infection from live vaccine strains 2, 3
• The immunosuppression caused by rituximab increases the theoretical risk of developing infection from live vaccine strains 7

Timing Considerations for Vaccination

• The American College of Rheumatology recommends withholding live-attenuated vaccines for at least 6 months after the last dose of rituximab 1
• The American College of Rheumatology recommends administering live vaccines before initiating rituximab therapy whenever possible 2, 3
• The European League Against Rheumatism recommends vaccinating with non-live vaccines before rituximab use whenever possible 2

Non-Live Vaccines

• The American College of Rheumatology notes that non-live vaccines may have reduced effectiveness in patients on rituximab, including reduced response to influenza vaccines 10, 3
• The American College of Rheumatology notes that non-live vaccines may have reduced effectiveness in patients on rituximab, including reduced response to pneumococcal polysaccharide vaccine (PPV23) 2, 3
• The American College of Rheumatology notes that non-live vaccines may have reduced effectiveness in patients on rituximab, including reduced response to tetanus toxoid (TT) vaccination in the first month after rituximab treatment 2

Special Considerations

• The American College of Rheumatology recommends administering tetanus immunoglobulin to patients with contaminated wounds who have been treated with rituximab in the past 6 months 2, 3
• The American College of Rheumatology recommends that patients receive pneumococcal and influenza vaccinations before starting rituximab whenever possible 2, 3
• The European League Against Rheumatism recommends checking antibody titers after vaccination to confirm adequate response 10, 6

Common Pitfalls and Caveats

• The American College of Rheumatology notes that some clinicians may not realize that the immunosuppressive effect of rituximab lasts for up to 6 months after the last dose 2, 3
• The American College of Rheumatology recommends considering tetanus immunoglobulin in addition to tetanus toxoid after exposure in rituximab-treated patients 2

Exceptions

• The American College of Rheumatology notes that in certain cases where the risk of infection outweighs the theoretical risk of vaccination, live-attenuated vaccines may be considered on a case-by-case basis 7
• The American College of Rheumatology notes that yellow fever booster vaccine has been reported safe in a very small number of patients on rituximab, but this is insufficient evidence to recommend routine use 10