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Immunizations in RA and SpA Patients - The Final Word
Dr. Shahin Jamal
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June 15 2017 9:44 PM ET — via RheumReports 
We are now getting better at recognizing and treating early joint inflammation, which leads to less disease progression, less damage and improved function. However, no therapy is without consequences, and one of the most important side effects of our treatments is increased risk of infection. This begs the question – do immunizations help? Will our immunosuppressed patients mount appropriate immune responses? Is there an ideal time to administer immunizations? Does the type of immunization matter?
At EULAR on Thursday, a group from France presented an eloquent systematic review attempting to evaluate immune response efficiency (IRE) and ideal timing of vaccination in RA and SpA patients on various immunosuppressive medications. They selected 35 of 60 studies evaluating immune responses (usually antibody titres) to influenza and pneumococcal vaccines in patients on MTX (n=35), TNFi (n=18), RTX (n=8), ABA (n=4) and TCZ (n=5).
Interestingly, they found that TNFi and TCZ do not impair immune responses to either influenza or pneumococcal vaccines and can be given any time in the course of treatment. Rituximab, not surprisingly, largely impairs immune response after vaccination to pneumococcal and influenza strains, with a compromised response lasting over 6 months after treatment. The limited data on abatacept suggests reduced immune response to anti-influenza vaccine and PCV7 but not to PPV23. The data on MTX were conflicting and confounded by co-treatment with biologics and steroids. Although there was usually some immune response mounted, this was blunted compared to non-treated subjects.
Bottom line: We should immunize all patients receiving TNF inhibitors and IL-6 inhibitors. Patients receiving methotrexate and abatacept still mount an immune response, albeit blunted, and should be immunized as well. Patients receiving rituximab should be immunized against pneumococcal infection prior to starting therapy. Influenza vaccine should probably still be administered but should be timed prior to their course of rituximab.
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About the Author
Dr. Shahin Jamal
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.
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