Vaccines & Rheumatology Patients

CHICAGO—Rheumatologists often come to Brian Schwartz, MD, associate professor of medicine and vice chief for clinical affairs in the Division of Infectious Diseases, University of California, San Francisco, with a concern: A patient on immunosuppression has a family member who needs a live vaccine, but the patient may be vulnerable to the vaccine’s effects. Should the family member get the vaccine?

The answer is yes, but precautions may be needed, Dr. Schwartz said during a session of the 2019 ACR State-of-the-Art Clinical Symposium, held April 5–7. His review of vaccinations in the context of rheumatic disease frequently touched on this theme: Vaccines are often advisable and safe for rheumatology patients—with caveats.

Family & Vaccines
In the case of a close family member getting a live vaccine, Dr. Schwartz said the benefits are worth it, even though “the person you’re most likely to get an infection from is probably the person you’re living with.”

Brian Schwartz, MD

“What I want to highly recommend—and recommend you to tell your patients—is that everybody in their family should get every vaccine that is recommended for them, because I really think a well-immunized family serves as a barrier to protect your patients from getting sick,” Dr. Schwartz said.

However, if a family member is getting a live influenza vaccine, the immunosuppressed person with rheumatic disease should avoid close contact. The patient should also be careful about contact with an infant who has just received a rotavirus vaccination, Dr. Schwartz said.

Effectiveness
When a rheumatologist is about to start a patient on treatment, it’s a good idea for patients and their physicians to consider vaccinations and think ahead, possibly holding off on starting a medication to ensure the vaccine can be effective, Dr. Schwartz noted.

“I want you to think about what you’re doing before you’re starting treatment, because that is the time you can get the most bang for your buck with a vaccine,” he said.

A 2017 study looking at flu vaccinations and methotrexate found patients who had methotrexate held for two weeks before the vaccine and for two weeks after, as well as those who had it held for four weeks after the vaccine, had a more robust response to the vaccine than patients who had methotrexate held for four weeks before or who didn’t have it held at all. However, at the last follow-up visit, patients who had methotrexate held during or after the vaccine experienced about triple the amount of flare—about 20%—compared with 7.5% for those who did not have it held.¹

Findings such as these leave it up to a clinician’s judgment to determine whether the benefit of the vaccination is worth the heightened risk of flare, Dr. Schwartz said.

Dr. Schwartz also reminded the rheumatologists in the room about the widespread risk of flu. Although patients may say, “I never get the flu,” and think they don’t need the vaccine, the reality is 43 million symptomatic flu cases occurred in the U.S. in the 2017–2018 season, as well as almost a million hospitalizations and about 80,000 deaths. Patients need to know “there’s a good chance [they’re] going to be affected by this,” he said.

Rheumatology patients who get the flu would benefit from treatment with oseltamivir even if symptom onset is longer than two days—an exception to the rule of thumb that treatment is not beneficial after 48 hours.

“You’re still going to reduce the risk of having a bad outcome” in these particularly vulnerable patients, Dr. Schwartz said.

For patients with a family member with flu and with whom they’ve had close contact, a preventive dose of oseltamivir once a day rather than twice a day can be beneficial even if they’ve shown no symptoms.

Zoster Vaccinations
Additionally, zoster vaccinations may become more feasible for rheumatology patients, Dr. Schwartz said.

An inactivated zoster vaccine, Shingrix, is now available, making it a more appealing option for immunosuppressed patients than the live version. The original clinical trials excluded patients with autoimmune diseases and organ transplant recipients. But a recent, randomized, controlled trial tested this by enrolling 264 kidney transplant recipients, and the results suggest it is safe and effective in that population.²

Patients in the trial were on a calcineurin inhibitor, steroids and mycophenolate mofetil. Immune responses were higher among those randomized to receive the vaccine, compared with placebo. Local adverse events were higher, but renal function changes, rejections and potential immune-mediated diseases were no more common in the treatment group than in the placebo group.

“I think the signals are really showing that this may be fine and would be efficacious,” Dr. Schwartz said. “I’m really excited about this vaccine.”

He also emphasized the importance of the HPV vaccine. Immunosuppression promotes persistence of the human papillomavirus, which is linked to a variety of cancers.

“Vaccination can reduce these risks, particularly if it’s given before one acquires HPV,” he said. Dr. Schwartz recommends all rheumatology patients under the age of 27 get the HPV vaccine.

Vaccines for Travel
Traveling abroad involves extra risk for rheumatology patients who are immunosuppressed, and vaccinations to prevent illness are not always possible. The yellow fever shot, a live vaccine, is contraindicated in most patients. But an alternative is to use DEET products for protection during travel. Patients can also get a waiver if they will be in a yellow fever-prone area for just a short time, Dr. Schwartz noted.

The typhoid intramuscular vaccine is acceptable, Dr. Schwartz said, but the oral vaccine is live and should be avoided, he stressed. The hepatitis A vaccine is also recommended, and if travel is less than two weeks away, an immunoglobulin injection is recommended.

Dr. Schwartz suggested people with rheumatic diseases take copies of their prescriptions and identify ahead of time the best hospitals in the areas they’ll be visiting.

And he had one more piece of advice: “I recommend they spend the extra money to purchase evacuation insurance. If they have a complication, they can come home and get care from their doctors.”

Thomas R. Collins is a freelance writer living in South Florida.

References

1. Park JK, Lee MA, Lee EY, et al. Effect of methotrexate discontinuation on efficacy of seasonal influenza vaccination in patients with rheumatoid arthritis: A randomized clinical trial. Ann Rheum Dis. 2017 Sep;76(9):1559–
2. Vink P, Ramon Torrell JM, Sanchez Fructuoso A, et al. Immunogenicity and safety of the adjuvanted recombinant zoster vaccine in chronically immunosuppressed adults following renal transplant: A phase III, randomized clinical trial. Clin Infect Dis. 2019 Mar 7. [Epub ahead of print]