Synopsis
Complete a reproducible infection and immunisation safety assessment before biologic or targeted therapy, interpret tuberculosis and hepatitis results correctly, and time vaccines without leaving active rheumatic disease untreated.
- Start with active infection: history, examination and symptom-directed tests come before latent-screen panels; a patient with sepsis or active TB does not proceed to biologic dosing.
- Tuberculosis assessment combines exposure and residence history, symptoms, IGRA and chest imaging when indicated. Immunosuppression can produce a false-negative or indeterminate IGRA.
- A positive latent-TB screen requires exclusion of active disease and referral to the TB service for preventive treatment and biologic timing; do not improvise a universal delay.
- Screen hepatitis B with HBsAg, total anti-HBc and anti-HBs. Surface antigen alone misses resolved infection that can reactivate during rituximab or other potent immunosuppression.
- If HBsAg or anti-HBc is positive, obtain HBV DNA and hepatology advice; B-cell depletion usually requires antiviral prophylaxis even when HBsAg is negative.
- Test hepatitis C antibody with reflex RNA because antibody alone cannot distinguish cleared from active infection; active HCV is now curable and should prompt a coordinated treatment plan.
- Offer HIV testing before advanced immunosuppression because undiagnosed infection changes opportunistic-infection risk, vaccine planning and the safest rheumatology regimen.
- Give indicated inactivated vaccines ideally before therapy, but they cannot cause vaccine infection during treatment; immune response may be weaker, especially after rituximab.
- Give a required live vaccine at least four weeks before significant immunosuppression when possible and avoid live vaccines during treatment unless an expert product-specific pathway permits one.
- Build a vaccine plan covering seasonal influenza and COVID-19 offers, pneumococcal vaccination, recombinant zoster and risk-based hepatitis B, HPV, travel and occupational vaccines.
Key red flags
Cough, weight loss, fever, night sweats, haemoptysis, lymphadenopathy or TB exposure requires active-tuberculosis assessment regardless of an earlier negative IGRA.
Jaundice, right-upper-quadrant pain, marked transaminase change or detectable HBV DNA requires hepatology assessment before immunosuppression.
A painful vesicular rash involving the eye, multiple dermatomes or systemic illness may be disseminated or ophthalmic zoster and needs urgent antiviral care.
Fever, hypotension, hypoxaemia, confusion, infected wound, hot joint or focal neurological signs means the infection work-up takes priority over scheduled biologic initiation.
Live vaccination accidentally given during significant immunosuppression requires immediate specialist risk assessment rather than the next biologic dose.
Pregnancy, planned conception or late-pregnancy biologic exposure changes vaccine and infant-live-vaccine decisions and must be documented before treatment starts.
Persistent cough, weight loss, sweats, fever, lymph nodes or organ-specific symptoms with epidemiological risk requires microbiological and imaging assessment, not a latency label.
Recent MMR, varicella or yellow-fever vaccination matters because replication occurs for a limited period and sets a minimum interval before significant immunosuppression.
Investigation priorities
Identify an active focus that makes immediate immunosuppression unsafe.
Management branches
Biologic or targeted treatment is planned and the patient enters the safety pathway.
- Take a structured symptom, exposure, travel, recurrent-infection, device, wound, dental and vaccine history and examine any likely focus.
- Investigate and treat active infection first, deferring immunosuppression when sepsis, active TB, uncontrolled hepatitis or significant untreated infection is credible.
- Proceed to latency, blood-borne-virus and vaccine assessment only when an active process has been addressed or safely excluded.