Why You Don’t Want to Get the Flu When You Have Rheumatoid Arthritis

COVID-19 isn't the only threat. Besides making you feel sick, tired, and miserable, the flu can be downright dangerous for those who have RA.

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flu shot for people with RA

A yearly flu shot is crucial for people with RA.

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The flu is a huge bummer for anyone, but if you have?rheumatoid arthritis, it’s even more of a threat. For one thing, rheumatoid arthritis (RA) is an autoimmune disease that disrupts normal immune function, so if you have this form of arthritis you’re more vulnerable to contagious illnesses such as influenza, says?Eric Ruderman, MD, the associate chief of clinical affairs for the division of rheumatology at Northwestern Memorial Hospital in Chicago. For another, you’re at higher risk for complications if you do get the flu.

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What Do People With RA Need to Know About the Flu Shot?

Both rheumatoid arthritis and RA treatment can increase your risk of complications from the flu. That’s why it’s so important for people with RA to get a flu vaccine, says Purvi S. Parikh, MD, of NYU Langone.
What Do People With RA Need to Know About the Flu Shot?

Factors That Increase Flu Vulnerability

People with RA have up to a 70 percent higher risk of any type of infection and as much as an 83 percent higher risk of an infection that requires hospitalization than their peers who don’t have this autoimmune disease, suggests research published in Arthritis & Rheumatology. Research published in the journal BMC Musculoskeletal Disorders found that people who have RA have a nearly 35 percent increased incidence of seasonal flu.

Also, because many people with RA take medications that suppress their overactive immune systems — such as corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and biologics — they’re at higher risk of flu infection overall, and it can be more serious, according to Dr. Ruderman.

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The Flu Brings the Risk of Complications

If you have rheumatoid arthritis and get the flu, the concern isn’t just that you’ll suffer from a fever, muscle and body aches, chills, a?sore throat, cough, nasal congestion, and fatigue (although that could be miserable enough). If you have RA and the flu, the risks of complications are higher: There's a greater likelihood of hospitalization, in addition to secondary bacterial infections like sinus infections, ear infections, bronchitis, and pneumonia, Ruderman says. “People sometimes think of the flu as just a bad cold. Anyone who has truly had influenza will tell you differently.”

Inflammation Threatens Heart and Lung Health

As it happens, people with RA have a 2.75-fold increased risk of complications (such as pneumonia, heart attacks, and?strokes) related to seasonal influenza regardless of whether or not they take?DMARDs or biologics, as the?BMC Musculoskeletal Disorders research noted. This isn’t shocking considering that besides affecting the joints, the chronically elevated inflammation that occurs with RA can cause problems for your lungs and heart even if you don't contract the flu, notes Ruderman.

Don’t Skip Your Flu Shot

Despite these potentially serious risks and the fact that rheumatologists consistently urge those with RA to get an annual?influenza vaccination, not everyone who has RA does. In?research published in April 2016 in?PLoS One, scientists found that 20 percent of people with rheumatoid arthritis didn’t receive a single influenza vaccination over a five-year period. That’s right: One in 5 people with RA shirked the flu shot each year for five years.

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Schedule a Flu Shot ASAP

A flu vaccine should be an annual tradition if you have RA, Ruderman says, so if your doctor doesn’t broach the subject, you should. Indeed, the?2019 guidelines from the European League Against Rheumatism (EULAR) suggest that the influenza and pneumococcal vaccines “should be strongly considered for the majority of patients with AIIRD,” short for autoimmune inflammatory rheumatic diseases, such as RA. As the 2019 EULAR guidelines noted, “Vaccination is particularly important in AIIRD patients, potentially translating into a lower rate of hospital admissions due to infections, emergency room visits and the rate of invasive infectious diseases.”

Just make sure you get the injectable flu vaccine, not the nasal spray. While the nasal spray isn’t generally contraindicated in patients with rheumatic diseases, notes Ruderman, it is contraindicated for those who are taking biologic therapy or strong immunosuppressive therapy (which does not include methotrexate). The reason: The inhaled flu vaccine contains live viruses, which could make you sick if you are immune-compromised because you have RA; by contrast, the injected flu vaccine contains the inactivated (or killed) strains of the virus, so it won’t make you ill.

Should You Consider Getting a High-Dose Flu Shot?

Talk to your doctor about whether you should get a high-dose influenza vaccine, though most recommendations suggest high-dose vaccines are just for those over age 65. A study published January 1, 2020, in the Lancet compared the immune effects and safety of a high dose versus the standard dose of an inactivated influenza vaccine on people with rheumatoid arthritis: Those who received the high-dose vaccine had a greater immune response against the flu, without having more side effects to the vaccine.

“It makes sense to aim for the highest antibody levels possible — therefore, people with RA should be given the high-dose vaccine if it’s available,” says?Stuart Kaplan, MD, the chief of rheumatology at Mount Sinai South Nassau Hospital in Oceanside, New York. “If it’s not readily available, then they should receive the standard vaccine, which is certainly better than nothing.”

Influenza Vaccination: Time It Right

Dosage issues aside, the sooner you get the influenza vaccine, the better, because it takes about two weeks for the shot to give you optimal protection against the flu. (The flu shot is usually available from September or October through the winter months.)

But don’t let your flu-fighting efforts end with the shot. You can take?additional steps to protect yourself from the flu as well as from?COVID-19: Wash your hands or use alcohol-based hand sanitizers regularly, and always do so before you eat. Avoid touching your mouth or eyes throughout the day, because this is often how germs enter your body. And steer clear of people who are noticeably sick. Remember: “Assume flu is out there,” Ruderman says. Measures such as social distancing and mask-wearing “absolutely help prevent the spread of any virus, not just COVID-19. Just look at the fact that there?was almost no influenza reported in the United States [the] winter when everyone was using these prevention behaviors,” Ruderman says.

What Should People With RA Do About Flu and Other Vaccinations, Such as COVID-19 Vaccinations or COVID-19 Booster Shots?

The short answer is: You should get them — and you don’t need to space them out. According to the Centers for Disease Control and Prevention (CDC), you can get the flu shot at the same time as your COVID-19 vaccine booster or other vaccines. The injections should be given in different sites, separated by at least an inch.

“Studies have shown that RA patients are more likely to contract COVID-19 than the general population — and they are more likely to have a more serious course,” Dr. Kaplan says. “Therefore, patients with RA and other autoimmune diseases are encouraged to stay up-to-date with COVID-19 vaccinations and boosters.”

In addition, the latest guidelines from the American College of Rheumatology advise people with RA who are under age 65 and on immunosuppressive medication to have the pneumococcal vaccination (for pneumonia) and those with RA who are over 18 and taking immunosuppressive medication to have the recombinant zoster vaccine (for shingles).