One of the last sessions at EULAR focused on viral infections. Vaccination before starting immunosuppressive treatment is ideal, however, this is not consistently put into practice.
A United Kingdom review of 17,877 patients with RA who were on DMARD therapy showed that only 79% of patients were given an influenza shot in any given year. Only 34% of patients received the expected 5 flu shots over the period studied. The uptake for pneumococcal protection was only 50%. Patients under 65 years of age had less uptake than those over 65. This is concerning given the increased rate of infection in patients with chronic inflammatory diseases.
Patients should be screened for Hepatitis B prior to starting DMARD therapy based on the possibility of reactivation during treatment. Although there is treatment for active HBV disease, it is not a cure and reactivation is always possible. Response to the hepatitis B vaccine once immunosuppressive treatment has been initiated is poor, therefore vaccination in advance of treatment initiation is strongly suggested. An algorithm for Hep B treatment is posted on the AGA website.
Dr Kevin Winthrop discussed the increased incidence of shingles in patients with chronic inflammatory diseases. In the normal population, the risk of shingles is 1 in 3 over a lifetime. This risk increases by 2-3 times in patients with RA and is even greater in patients with SLE. The risk is also heightened in PsA, AS, psoriasis, gout and IBD. Four American retrospective analyses have not shown an additional increase in risk in patients on anti-TNF therapy, which has been reported in European cohorts. Steroid use does increase risk in a dose-dependent manner. Of all the biologics, abatacept may have the lowest risk. JAK inhibitors appear to have a class effect of further increasing shingles risk, especially on a background of MTX. This risk is further increased with the addition of steroids.
One positive aspect is that patients who do get shingles while on anti-TNF therapy have less reports of post-herpetic neuropathy than the general population. The message again is to vaccinate before treatment!!
A new inactivated adjunct vaccine is being developed for shingles and it may offer a higher rate of protection. A NIH-funded study is evaluating the safety of the current live vaccine administered while on any type of DMARD therapy. Accidental administration of the shingles vaccine while on biologic DMARDs has not shown harm. The new study will hopefully provide a definitive answer.
Pneumonia has a higher incidence in RA patients and vaccination for those over age 50 is suggested with the conjugate vaccine, followed 8 weeks later with the older polysaccharide formulation.
Chikungunya is a virus spread by daytime-biting mosquitoes and is on the rise in many countries in the Caribbean and in the Southern United States. It can survive in containers and is easily spread during travel. Common symptoms include arthralgia, which can persist for months, carpel tunnel syndrome, fever, rash, headache and diarrhea. IgM titres peak 2-3 weeks after contracting the virus and IgG titres are positive at 2 weeks. On assessment, joint effusions have a different presentation than RA.
Treatment of Chikungunya infection at the UK Hospital for Tropical Disease includes an initial prescription of naproxen 500 mg b.i.d. followed by steroids. Immunosuppressive treatments may be used third-line but there has been minimal use to date.
Carolyn Whiskin, BSc. Phm is currently the director of pharmacy programs for the Charlton Centre for Specialized Treatments in Hamilton, Ontario. She also practices pharmacy at Brant Arts Dispensary in Burlington, Ontario and is the pharmacist representative to the Ontario Rheumatology Association’s Model of Care committee.View Full Bio