In this session, Dr. Jeffrey Curtis shared insights regarding the use of vaccines in patients receiving biologic therapies, non-biologic DMARDs and systemic steroids. The newly published ACR 2015 Guidelines for RA provide recommendations regarding vaccination for patients while on DMARD and biologic therapies.
As presented at last year's ACR, methotrexate is known to blunt the effectiveness of pneumococcal vaccines and may decrease the effectiveness of influenza vaccines as well. These vaccines should still be administered to patients receiving these treatments, however, for optimal benefit, adult vaccines should be updated when patients enter a practice or while waiting for a referral to a rheumatologist. Since methotrexate's impact on decreasing vaccine effectiveness could last for several weeks after discontinuation, it is not advisable to hold methotrexate at the time of vaccination.
The most significant blunting of vaccine benefit is seen with rituximab. Vaccinations should be administered one month prior to the next dosing sequence; 6 months after the first dose if possible.
The incidence of Herpes Zoster (HZ) increases with age and at a greater rate for patients with RA and lupus. The risk attributed to healthy individuals aged 61-70 is seen at age 31-40 in people with RA and even earlier in those with lupus. There is a 1.5 to 2-fold further increase in the incidence of HZ with the use of prednisone at 7.5mg or greater. As the current HZ vaccine is live, there has been concern regarding its administration while on DMARDs including biologics. Reassuringly, inadvertent administration of the vaccine to 633 patients on combination biologic and DMARD therapy in the USA resulted in no cases of shingles.
Dr. Stephen Lindsey shared his personal clinic data whereby he administered the HZ vaccine to 180 patients with inflammatory arthritis at the time of their next biologic dose while holding the biologic. All other DMARDs were maintained. Biologic therapy was then resumed 2 weeks later. Not one patient had a case of shingles and all had a positive immune response. The Verve Zoster Vaccine Trial is now underway and recruiting patients. This trial will randomize 1,000 RA patients over age 50 on anti-TNF therapy to vaccine or placebo.
The durability of the HZ vaccine appears to be up to 10 years in the healthy population but only 5 years in patients with RA. The question is, how effective is a booster and when should it be given? It is thought that the benefit of reducing post-herpetic neuropathy may extend beyond 5 years and this may affect the timing of a booster. Canadian guidelines released last year support the administration of the HZ vaccine while on anti-TNF therapy with consult by an expert in immunology.
The comfort of clinicians, especially those in general practice, with giving the HZ vaccine is still low. I am hopeful this information will encourage greater use of this vaccine.
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