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Update on Vaccines in Autoimmune Patients

Although both the disease and the treatment for it in rheumatology patients may work at cross-purposes with immunizations, only a very few vaccines are absolutely contraindicated in this population, an infectious disease specialist told rheumatologists here.

Those are certain of the live-virus vaccines, and only one -- rotavirus vaccine for infants born to women receiving immunosuppressants -- is in widespread use with no suitable alternative, said Brian Schwartz, MD, of the University of California, San Francisco.

So, while the intranasal live-virus influenza vaccine FluMist isn't safe "for most of your patients," the inactivated-virus products should be adequate in nearly all cases, he told attendees at the American College of Rheumatology's State of the Art Clinical Symposium

The issue, of course, is that patients with rheumatoid arthritis, lupus, scleroderma, or other autoimmune diseases already have dysfunctional immune systems, and the treatments they typically receive disrupt immune function even further. Yet these patients are still subject to vaccine-preventable infections, such that it remains prudent to provide vaccinations whenever possible -- which, Schwartz said, is most of the time.

Specific risks and solutions vary with the disease and treatment, but the principal risks from the vaccination itself come with live-pathogen vaccines. For bacterial diseases, these include the oral typhoid vaccine and Bacillus Calmette-Guerin (BCG) for tuberculosis, although BCG is no longer commonly used in the U.S.

On the virus side, besides FluMist, live-virus products include the measles-mumps-rubella products; Varivax and Zostavax (but not Shingrix) for childhood chickenpox and adult shingles; the yellow fever vaccine; and the infant rotavirus vaccine.

Risks with live-virus vaccines are particularly prominent with a number of common treatments for autoimmune disease: high-dose steroids, cyclophosphamide, methotrexate, azathioprine, tumor necrosis factor inhibitors, and others.

While live-virus vaccines are best avoided in patients with autoimmune diseases, the question often comes up as to whether patient's household contacts can safely receive them, because they may shed the vaccine virus. Schwartz said it's not really a problem for most vaccines, but there are exceptions: "close contacts should avoid live influenza vaccine," and patients should avoid contact with infants who have recently received the rotavirus or oral polio vaccine.

Schwartz also noted that one way to avoid problems with live-virus vaccines is to make sure patients -- and their household contacts -- are up to date on vaccines before starting treatment with immune modulators.

It's true that vaccine efficacy can be reduced in patients on treatment for rheumatic diseases, but in some cases use of antivirals can make up for it, Schwartz said. He recommended liberal use of oseltamivir (Tamiflu) in patients who show flu symptoms -- starting it before diagnosis is confirmed and/or when more than 48 hours have elapsed since symptom onset. Similarly, anti-zoster drugs can be used in patients.

Increasing the influenza vaccine dose can also help overcome the lowered response, he said. Yet another strategy for patients on methotrexate at risk for flu, backed by trial data, is to stop the drug briefly beginning at or just before the vaccine is given and resuming it after 2 weeks.

Another concern, among younger patients especially, is risk for human papillomavirus. "Immunosuppression promotes HPV persistence ... and risk for HPV-associated cancers," Schwartz said. He urged rheumatologists to be vigilant in recommending the HPV vaccination for patients younger than 27.

He closed his talk by discussing vaccines and other risk-reduction tactics for international travelers. Patients on immunosuppressants need to be particularly cautious: avoiding exposure to mosquito-borne infections and preparing to cope if, despite precautions, patients do become infected. (For example, Schwartz recommended buying evacuation insurance and identifying in advance "the best hospitals" at destinations.)

There's not much to be done about yellow fever, he admitted -- the only available vaccine is a live-virus product contraindicated for immunocompromised patients, and is in shortage to boot. Patients can get medical waivers when proof of vaccination is required for travel.

In the case of typhoid, although the live-pathogen oral vaccine can't be used, the intramuscular vaccine is acceptable. Schwartz also recommended that travelers get hepatitis A vaccines and, if less then 2 weeks before starting travel, anti-hepA immunoglobulin.

He urged the audience to refer patients to travel-medicine specialists when possible.

Schwartz said he had no relevant financial interests.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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