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Inflammatory Arthritis Flu Vaccine

Getting a flu vaccine is important every single flu season, especially if you have a form of inflammatory arthritis such a rheumatoid arthritis (RA), psoriatic arthritis (PsA), or axial spondyloarthritis (axSpA) — but in the midst of the COVID-19 pandemic, it’s even more critical.

“Although measures taken for COVID-19 protections may have suppressed the most recent flu season in the United States, the influenza virus remains one the single deadliest infections today,” according to Robert Popovian, PharmD, MS, Chief Science Policy Officer at the Global Healthy Living Foundation and a senior health policy fellow at the Progressive Policy Institute, in a recent article on MorningConsult.com.

That’s why the U.S. Centers for Disease Control and Prevention (CDC) and rheumatology experts are urging patients to get the flu vaccine this year. The good news is that many people with chronic illness don’t need convincing.

“As we are getting ready to enter flu season [in the U.S.], and with COVID-19 continuing to spread throughout our communities, I think it is extremely important for people to get the flu vaccine this year,” says Justin Owensby, PharmD, PhD, a research pharmacist in the division of clinical immunology and rheumatology at the University of Alabama at Birmingham (UAB).

“As the novel coronavirus has severely stressed our health care system/resources, having even a mild flu season will further tax the system,” which may lead to even more strain on the hospitals and health care workers who will help you if you end up needing emergency care because of flu complications such as pneumonia, adds Dr. Owensby.

Here’s more about why, when, and how to get your flu vaccine safely this year.

Why You Need the Flu Vaccine, Period

First, simply having inflammatory arthritis increases your chances of getting the flu — and, if you do catch it, your risk of serious infection and severe complications is greater.

“Compared to the general population, people living with inflammatory arthritis are at substantially higher risk of getting a vaccine-preventable infection, such as the flu or pneumonia, and consequently more complications and hospitalizations from those infections,” explains Dr. Owensby.

For example, RA patients have nearly a three times greater risk of getting the flu than healthy patients in the same age group, according to a 2012 analysis of 46,030 RA patients and an equal number of healthy controls, published in the journal BMC Musculoskeletal Diseases.

Yet another study, presented as an abstract at the American College of Rheumatology conference in 2018, found that RA patients who get influenza experience increased hospital stays as well as higher costs compared to healthy controls.

Inflammatory arthritis decreases your body’s natural immune defenses and some disease-modifying medications used to manage your condition can also weaken your immune response. “The flu shot is designed to strengthen your immune system by allowing it to recognize and fight off an influenza infection,” says Owensby. “Flu vaccines have been shown to reduce the risk of flu illness, hospitalization, and death.”

COVID-19 and Flu Coinfection

As if that’s not convincing enough, here’s yet another reason to roll up your sleeve: “People can get coinfected with influenza and COVID-19, says Jeffrey Curtis, MD, MS, MPH, professor of Medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham (UAB). “You can have both infections at the same time, and if that happens, the severity will be much worse.”

While the flu shot won’t protect you from getting COVID-19, it may help reduce the risk of spreading COVID.

“If you have the flu, and you’re coughing and sneezing, common sense says you’re more likely to transmit COVID,” says Dr. Curtis, “so if you can decrease the incidence and transmission of influenza, then you it’s possible that you can decrease the transmission to COVID.” More research is needed to confirm this effect, however.

How Do You Tell the Difference Between Cold and Flu?

Since symptoms of the flu and COVID-19 are similar, the only way to tell for sure is to be tested. According to the CDC, symptoms that COVID-19 and flu share include:

  • Fever or feeling feverish/having chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Sore throat
  • Runny or stuffy nose
  • Muscle pain or body aches
  • Headaches
  • Vomiting and diarrhea
  • Change in or loss of taste or smell (which is more frequent with COVID-19)

When Should I Get the Flu Vaccine?

The CDC recommends getting your flu shot before influenza spreads within your area; ideally by the end of October. However, getting vaccinated anytime during the flu season, even in January or later, can protect you.

Dr. Curtis says it’s important to remember that it takes about two weeks after vaccination for antibodies that protect against flu to develop in the body — and that immunity doesn’t always last the entire season.

“There is some temporariness to the duration of protection of the flu vaccinations, so if you get the flu shot in September, it might not offer the same protection in March,” he says. Yet if putting it off until November means you might just put it off forever, Dr. Curtis urges patients to get it done and over with it when it’s top of mind.

If you suspect you may have been exposed to COVID-19 or have a confirmed diagnosis of COVID-19, the CDC suggests delaying the flu shot until you’re no longer showing signs and symptoms, adds Dr. Owensby.

This isn’t because there’s evidence that having COVID affects the effectiveness of the flu vaccination, but rather because you don’t want to unnecessarily expose others to COVID-19.

Can I Get the Flu Shot and COVID-19 Vaccine at the Same Time?

According to the CDC, you can get the flu vaccine at the same time as the COVID-19 vaccine, including a third dose or booster dose of the COVID-19 vaccine. Past research has shown the way our bodies develop protection and possible side effects are generally similar, whether the vaccine is given alone or with another vaccine.

“It is largely at the discretion of the individual,” says S. Louis Bridges, Jr., MD, PhD, Physician-in-Chief and Chief of the Division of Rheumatology at the Hospital for Special Surgery. “In general, co-administration of vaccines has been effective and safe over decades in adults and in children, and there is no evidence that giving flu vaccine and COVID-19 vaccine simultaneously raises any safety concerns.”

There are advantages and disadvantages to consider, however. The advantage: You’ll only need to go once for protection against two different vaccines — and “the vaccines will protect against infection sooner than if dosing of the vaccine is delayed,” notes Dr. Bridges. The disadvantage: With two shots, “side effects such as soreness at the site of injection, fever, and fatigue may be more common,” he adds.

What’s the Best Place to Get the Flu Vaccine?

If you have a scheduled visit at your rheumatologist or primary care physician, you can always ask if they are offering the flu shot. Heading to your local pharmacy is also an option, but you’ll want to be sure to wear your mask and practice social distancing and proper hygiene. You can also call ahead to ask about how crowded the facility is and find out the times of day when it’s likely to be emptiest.

“It doesn’t matter where as long as you get one,” says Dr. Owensby. He recommends using VaccineFinder.org to find where flu vaccines are available near you. “[And] when going to get a flu vaccine, be sure to practice everyday preventive actions.”

What Type of Flu Shot Is Best?

Dr. Curtis says there are three considerations for people with inflammatory arthritis:

Is it a live vaccine?

A live vaccine, such as the nasal spray, can cause side effects in people with inflammatory arthritis who have weakened immune systems. Instead, opt for the flu shot, which is made from inactivated (or killed) influenza virus, which cannot cause illness.

Is it quadrivalent?

According to the CDC, all flu vaccines for the 2021-2022 season will be quadrivalent. This means that it’s a four-component vaccine, which this year protect against the following four flu strains: A/Hawaii/70/2019 (H1N1) pdm09-like virus; A/Hong Kong/45/2019 (H3N2)-like virus (updated); B/Washington/02/2019; (B/Victoria lineage)-like virus (updated), plus B/Phuket/3073/2013-like (Yamagata lineage) virus. The trivalent vaccine, which offers protection against three strains, does not include the fourth virus, B/Phuket/3073/2013-like (Yamagata lineage) virus.

Is it high-dose?

This is a more potent type of flu vaccine, and while it’s generally reserved for adults 65 and older, it is beneficial for people with inflammatory arthritis who may have a weaker response to the flu vaccine than people without these health conditions. In fact, research published in The Lancet Rheumatology reported that the high-dose flu shot (Fluzone) substantially improved the immune response in seropositive RA patients compared to the standard-dose flu shot. However, many high-dose vaccines are trivalent, and don’t protect against B/Phuket/3073/2013-like (Yamagata lineage) virus.

Talk with your rheumatologist about the best type of flu vaccine for you, and be sure to check with your insurance to see if it’s covered, says Dr. Curtis. Although most private and public insurance plans will cover the flu vaccine at no cost to the patient.

Do I Need to Adjust My Arthritis Medications?

While the decision to adjust your medications should be between you and your rheumatologist, there are studies showing that some medications, including high doses of steroids, methotrexate, and the biologic rituximab, reduce the body’s immune response to flu vaccine, says Dr. Owensby.


Treatment with the infused drug rituximab has been shown to decrease the response to the flu shot, says Dr. Owensby, so your doctor may recommend delaying the time between vaccine and your next infusion.


Recent studies have shown that a brief, two-week discontinuation of methotrexate after receiving the flu shot can boost your immune response to it, says Dr. Owensby.

Although researchers have also found that people taking methotrexate or TNF inhibitor biologics — like etanercept (Enbrel), adalimumab (Humira), and infliximab (Remicade) — do have an acceptable response to the flu vaccine, the response isn’t as strong as it is in healthy individuals who are not taking immunosuppressants.

Your best bet is talk to your doctor about the pros and cons of skipping a dose of your medication around the time you get your flu shot. Dr. Curtis emphasizes that people should not “stop taking medication prematurely,” without consulting their doctors.

Can the Flu Shot Increase My Risk of Getting Sick?

“To my knowledge, there is no evidence suggesting getting a flu shot will make you more susceptible to COVID-19,” says Owensby. “Although they are both contagious respiratory illnesses, they are caused by different viruses.” COVID-19 is caused by SARS-CoV-2 and flu is caused by different strains of influenza viruses.

Similarly, getting the flu shot will not give you the flu, says Dr. Curtis. In fact, those mild flu-like symptoms you may experience after the shot — headache, achiness, malaise, low-grade fever — are all signs of your immune system revving up to protect against the flu, he explains.

Keep Practicing Mask Wearing, Social Distancing, and Good Hygiene

While experts agree that you need to get a flu shot, it doesn’t mean you should stop taking other precautions to stay healthy this flu season.

“Even after receiving the flu shot, it’s still important to take all the steps you can to avoid getting the flu,” says Owensby.

So, get vaccinated, amp up your efforts to eat well and exercise, prioritize sleep, manage stress, and of course, practice a whole lot of hand washing and sanitizing.

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Blumentals WA, et al. Rheumatoid arthritis and the incidence of influenza and influenza-related complications: a retrospective cohort study. BMC Musculoskeletal Disorders. August 2012. doi: https://doi.org/10.1186/1471-2474-13-158.

Colmenga I, et al. Immunogenicity and safety of high-dose versus standard-dose inactivated influenza vaccine in rheumatoid arthritis patients: a randomised, double-blind, active-comparator trial. The Lancet Rheumatology. January 2020. doi: https://doi.org/10.1016/S2665-9913(19)30094-3.

 Frequently Asked Influenza (Flu) Questions: 2021-2022 Season. Influenza. U.S. Centers for Disease Control and Prevention. September 22, 2021. https://www.cdc.gov/flu/season/faq-flu-season-2021-2022.htm.

Interview with  S. Louis Bridges, Jr., MD, PhD, Physician-in-Chief and Chief of the Division of Rheumatology.

Interview with Jeffrey Curtis, MD, MS, MPH, professor of medicine in the division of clinical immunology and rheumatology at the University of Alabama at Birmingham (UAB).

Interview with Justin Owensby, PharmD, PhD, a research pharmacist in the division of clinical immunology and rheumatology at the University of Alabama at Birmingham (UAB).

Interview with Robert Popovian, PharmD, MS, Chief Science Policy Officer at the Global Healthy Living Foundation and a senior health policy fellow at the Progressive Policy Institute.

Perry LM, et al. Vaccinations for Rheumatoid Arthritis. Current Rheumatology Reports. June 2014. doi: https://doi.org/10.1007/s11926-014-0431-x.

Venkatesh PGK, et al. Impact of Rheumatoid Arthritis on Influenza-Related Complications: A Population Based Cohort Study [abstract]. Arthritis & Rheumatology. October 2018.  https://acrabstracts.org/abstract/impact-of-rheumatoid-arthritis-on-influenza-related-complications-a-population-based-cohort-study.

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