In an attempt to protect our patients on biologics from infection, vaccinations are advisable. But given the immunosuppressive nature of RA, both because of active disease and the treatments we use, what do we know about the success of vaccinations in our patients? While some data exist for other vaccines, it is much more limited for Hepatitis B.
This morning there was a thought-provoking trial from The Netherlands entitled "Protection by Hepatitis B Vaccination of RA Patients Using Biologics." The investigators looked at 47 RA patients compared with 156 health care workers as a control group. Vaccination was done as per usual protocol and anti-HBs levels were measured at 28 weeks.
Responder rates to the vaccine (described as anti-HBs levels greater than 10 IU/l) were statistically significantly lower in the RA group, only 11% compared with 83% in the control group. Among the non-responders there was no difference based on treatment with anti-TNF therapy vs DMARDS or rituximab.
Another study previously showed responder rates of 68% in RA patients. During the question period, it was suggested this difference might be due to the particular vaccine (HBVax) used in this trial compared to EnergixB used in the previous study, which may be more potent, and the fact that no anti-TNF agents were included in the older study.
Assuming these results represent a real inadequate response in our RA patients, what can we do about this? Options discussed include vaccinating before anti-TNF agents are started or even before DMARDS if possible, consider increasing the dose of the vaccine, or administering another booster dose.
Based on these shockingly poor results, I would suggest a stronger push to vaccinate early our at-risk patients despite the challenges this poses!
Dr. Shelley Dunne is a graduate of Memorial University of Newfoundland School of Medicine. She completed her training in Internal Medicine and a fellowship in Rheumatology at the University of Toronto. She has been in private practice since 1998 and is currently a consulting rheumatologist at the Toronto East General Hospital.View Full Bio