Before starting a biologic for ankylosing spondylitis, your rheumatology team should review your vaccine record and offer any vaccines you are due for. Vaccines such as influenza, COVID-19, pneumococcal, and shingles may be relevant depending on your age, health, prior doses, and local guidance. Live vaccines often need to be given before treatment, while most non-live vaccines can be given during treatment but may work less well.
Why should you review vaccines before starting biologics?
Biologic medicines, including tumour necrosis factor (TNF) inhibitors and interleukin-17 (IL-17) inhibitors, target parts of the immune system involved in inflammation. These medicines can affect how the body responds to infections and vaccines. Reviewing vaccination status before treatment helps identify opportunities to protect against preventable infections when vaccine responses may be better.
The American College of Rheumatology (ACR) recommends reviewing and updating appropriate vaccinations in people with rheumatic and musculoskeletal diseases who receive immunosuppressive medicines. Its guidance also distinguishes between live and non-live vaccines because their safety and timing considerations differ.
You do not necessarily need every available vaccine before starting treatment. The appropriate vaccines depend on your vaccination history, age, other medical conditions, exposure risks, planned medication, and the immunisation recommendations in your country.
Which vaccines should you discuss with your rheumatologist?
Your clinician will compare your vaccination record with the recommended schedule for your age and circumstances. If records are missing, the team can help determine whether you need additional doses or other steps to confirm your vaccination status. The US Centers for Disease Control and Prevention (CDC) adult immunisation schedule illustrates how recommendations vary according to age, vaccination history, and individual risk factors. Other countries may use different schedules.
Influenza vaccine
Seasonal influenza vaccination is generally recommended for people receiving immunosuppressive treatment when indicated by local guidance. Before starting a biologic, check whether you are due for the current season's vaccine. The injected inactivated influenza vaccine is different from the live attenuated nasal spray vaccine. People receiving immunosuppressive medicines generally need to avoid live vaccines unless their specialist has established an appropriate plan.
COVID-19 vaccine
Review whether you are up to date with COVID-19 vaccination under the recommendations that apply to you. People whose immune systems are weakened by disease or treatment may have a greater risk of serious infection and may qualify for a specific vaccination schedule. The CDC's COVID-19 vaccination guidance for immunocompromised people explains that vaccination timing and the number of doses depend on factors such as age, immune status, and previous vaccination. Your rheumatologist can help coordinate vaccination with the planned biologic treatment.
Pneumococcal vaccine
Pneumococcal vaccines help protect against infections caused by Streptococcus pneumoniae, including certain forms of pneumonia and invasive pneumococcal disease. These vaccines may be particularly relevant for people receiving immunosuppressive treatment. Whether you need a dose, which vaccine is appropriate, and whether additional doses are necessary depend on your age, previous vaccinations, medical history, and national recommendations.
Shingles vaccine
Shingles develops when the virus that causes chickenpox becomes active again. A recombinant shingles vaccine is a non-live vaccine and may be recommended for people who are or will be immunosuppressed. For example, the CDC recommends recombinant zoster vaccine for immunocompromised adults aged 19 years and older in the United States. Eligibility and availability vary by country. If you are eligible, discussing vaccination before starting a biologic may help with planning.
Other routine and risk-based vaccines
Your clinician may also review tetanus, diphtheria, pertussis, hepatitis B, human papillomavirus (HPV), measles, mumps, rubella (MMR), and chickenpox (varicella) vaccination, as appropriate. These are not all required for every person with ankylosing spondylitis. The choice depends on previous doses, age, immunity, travel plans, exposure risks, and the type of vaccine involved. Hepatitis B testing may also be part of a separate pre-treatment assessment, depending on clinical circumstances and the planned medicine.
Which vaccines are live, and which can be given during biologic treatment?
Vaccine type is one of the most important considerations before treatment. Live attenuated vaccines contain a weakened form of a virus or bacterium. Non-live vaccines use inactivated organisms, selected proteins, or other components rather than a live organism capable of reproducing in the body.
Common examples of live vaccines include MMR, varicella, yellow fever, and the live attenuated nasal spray influenza vaccine. The exact recommendations depend on the vaccine and the person's immune status. Many routine vaccines, including injected inactivated influenza vaccines, pneumococcal vaccines, recombinant shingles vaccines, and currently used COVID-19 vaccines, are non-live.
According to the CDC guidance on altered immunocompetence, live vaccines can pose safety concerns for people whose immune systems are suppressed. Such vaccines are generally avoided during treatment with immunosuppressive medicines unless a specialist determines an appropriate approach. Non-live vaccines can generally be administered safely during immunosuppression, although the immune response may be weaker than expected.
How long before a biologic should you get vaccinated?
Ideally, any needed vaccines should be reviewed early enough to allow appropriate doses and intervals before treatment begins. There is no single waiting period that applies to every vaccine and biologic medicine.
As a general reference, CDC guidance advises allowing at least two weeks between a non-live vaccine and the start of immunosuppressive therapy, and at least four weeks after a live vaccine when initiating such therapy. These intervals are general guidance rather than a personalised prescription. Your rheumatologist may recommend a different plan according to the vaccine, medicine, and urgency of treatment.
Some vaccines require more than one dose, with weeks or months between doses. This means it is helpful to discuss vaccination as soon as a biologic is being considered rather than waiting until the proposed start date. If your ankylosing spondylitis needs treatment promptly, the team should balance vaccine timing against the risks of leaving inflammation inadequately treated. Necessary treatment should not be postponed automatically just because a vaccine is due.
Can you receive vaccines after starting a biologic?
Yes. Starting a biologic does not mean you can no longer receive vaccines. Most non-live vaccines remain options during treatment, although the degree of protection may depend on the medication and the person's immune response. Your clinician may recommend a particular timing to improve the likelihood of a useful response.
Some people may be advised to adjust the timing of a medication around vaccination. These decisions are medicine-specific and should take account of disease activity and the risk of a flare. Do not stop, skip, or delay your biologic dose independently to get vaccinated.
If you have already started treatment and discover that you need a live vaccine, contact your rheumatology team before arranging it. The team can assess the risks, identify appropriate intervals around your specific medication, and consider whether an alternative vaccine or a carefully planned treatment adjustment is appropriate.
Does age affect vaccine recommendations?
Age can influence which vaccines are recommended, the number of doses needed, and the intervals between doses. Children and adolescents with juvenile-onset spondyloarthritis follow age-appropriate immunisation schedules, with specialist input when immunosuppressive treatment is planned. Adults may need routine boosters or additional vaccines based on their health and treatment. Older adults may also have different routine recommendations from younger adults.
Pregnancy, a history of certain infections, previous severe vaccine reactions, immune deficiencies, and travel to areas where particular infections occur can also affect vaccine decisions. Tell your clinician about these circumstances so that your plan reflects your needs rather than a standard checklist alone.
Are vaccines the only safety checks needed before biologics?
No. Vaccination review is one part of preparing for biologic treatment. Your healthcare team may also arrange screening for infections that could become more serious during treatment. For example, the ASAS-EULAR recommendations for axial spondyloarthritis provide the treatment framework for this condition, while the separate EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections recommend screening for latent tuberculosis before starting biologic or targeted synthetic disease-modifying treatment.
Depending on your planned medicine and medical history, your clinician may also consider hepatitis B screening and other relevant tests. These checks are different from vaccination: a vaccine helps prevent a particular infection, whereas screening looks for an infection or evidence of previous exposure that may affect treatment choices.
What should you prepare for your vaccination review?
Bring any available vaccination records to your rheumatology appointment, including records from childhood, previous clinics, or workplace vaccination programmes. Tell your clinician about recent vaccines, previous reactions, known vaccine-preventable infections, allergies, travel plans, and any other medicines you take.
It is also useful to confirm the name of the planned biologic and the intended start date. Different medicines have different effects on the immune system, so this information helps your team decide which vaccines are most important, which should be given first, and whether any waiting period is appropriate.
The aim is to bring your vaccination status up to date as safely and efficiently as possible without creating unnecessary delays in managing ankylosing spondylitis. A personalised plan can help you prepare for treatment while reducing avoidable risks from vaccine-preventable infections.