Background/Purpose: The guidelines for the management
of rheumatoid arthritis (RA) recommend an annual influenza vaccine and a
pneumonia vaccination (EULAR, 2011), prior to starting disease-modifying
anti-rheumatic drug (DMARD) therapy. It is not clear how well these guidelines
are adhered to in the UK. This study aimed to measure the extent to which
patients with RA are vaccinated in the UK, and to determine the timing of the
vaccinations in relation to starting DMARD therapy.

Methods: This was a retrospective cohort study using
data from the Clinical Practice Research Datalink (CPRD). An inception cohort
of adult patients, diagnosed with RA and prescribed DMARD therapy during
follow-up (1^st January 2000 – 31^st December 2013) were identified.
Vaccination status was considered as follows: 1) Influenza: The influenza
season was estimated to start on 1^st September each year and all
patients were considered unvaccinated at this point. Patients were considered
vaccinated if they received an influenza vaccine between 1^st September
and 31^st August the following year. 2) Pneumonia: Following vaccination
patients were considered vaccinated for the rest of follow-up. For both
influenza and pneumonia vaccines, descriptive statistics show i) the proportion
having at least one vaccination, ii) the observed and expected use and iii) the
proportion of first vaccinations occurring prior to DMARD therapy initiation. Patients
were stratified by age 65 at the start of follow-up, given differences in
vaccination guidelines for the general population.

Results: There were 17877 patients with RA identified
who were treated with DMARD therapy during follow-up (median follow-up 5.1
years).

Age below 65 years (N=11391): 8309 (73%) patients had
received at least one influenza vaccination, of whom 3021 (36%) were vaccinated
prior to starting DMARD therapy. Of those expected to have up to 5
vaccinations, 20% – 30% received all expected vaccinations. There were 4960 (44%)
patients who had received at least one pneumonia vaccination, of whom 1269 (26%)
were vaccinated prior to starting DMARD therapy.

Age 65 years and over (N=6486): 5858 (90%) patients received
at least one influenza vaccination, of whom 4590 (78%) were vaccinated prior to
starting DMARD therapy. Of those expected to have up to 5 vaccinations, 55%-75%
received all expected vaccinations. There were 4026 (62%) patients who received
at least one pneumonia vaccination, of whom 2498 (62%) received a vaccination
prior to starting DMARD therapy (Table 1).

Conclusion: One in five patients received no
influenza vaccine and 1 in 2 patients received no pneumonia vaccine over 5
years of follow-up. Of those vaccinated, only half of patients were vaccinated
prior to initiating DMARD therapy. In a five year period, only 1 in 3 patients
received regular annual influenza vaccines. There remains significant scope to
improve the uptake of vaccinations in patients with RA.