Which immunosuppressives should be held around influenza vaccination?

• A. Methotrexate and Leflunomide
• B. Rituximab and Adalimumab
• C. Methotrexate and Cyclosporine
• D. Methotrexate and Rituximab

Answer: (D)

The key idea is to optimize the immune system’s ability to respond to the vaccine while the patient is on immunosuppressive therapy. Methotrexate can dampen the body's antibody response to vaccines, so pausing it briefly around the time of influenza vaccination improves seroconversion without causing major disease flares in many patients. Rituximab, on the other hand, depletes B cells, which are essential for producing new antibodies to a vaccine. Because of this, vaccines given during active rituximab-induced B-cell depletion generate a poor antibody response; the best approach is to vaccinate before starting rituximab or to time vaccination for periods when B cells have reconstituted after infusion. Taken together, these considerations support holding methotrexate and rituximab around influenza vaccination to maximize vaccine effectiveness. Other agents like Leflunomide, Adalimumab, or Cyclosporine don’t have as strong, consistent guidelines requiring routine holds for influenza vaccination, so vaccination can often proceed without interrupting those therapies, tailored to individual disease control and risk.