Efficacy of Pneumococcal Vaccine in RA Patients Save

Infection is a major cause of morbidity and mortality in RA patients and thus vaccinating against preventable infections is a top priority for rheumatologists. Numerous studies have looked at efficacy and immunogenicity of various vaccines in this population and it is known that RA treatments may reduce efficacy.

In the current issue of Arthritis Research & Therapy a Japanese group designed a study to assess efficacy of the pneumococcal polysaccharide vaccine (PPSV23) in preventing pneumococcal pneumonia and pneumonia overall in RA patients. In a prospective, multicenter, double-blinded, RCT they randomly assigned 900 RA patients who had been treated with biologics or immunosuppressive agents to receive either PPSV-23 or placebo. Primary endpoint was incidence of all-cause pneumonia and pneumococcal pneumonia.

They found no difference in rates of developing pneumonia between the two groups, with 3.7% of the vaccine group and 3.4% of the placebo group developing pneumonia for an overall rate of 21.8/1000 PYs. These findings disagree with previous studies that show while biologics and in particular methotrexate may results in diminished response to PPSV23, it still is efficacious in this groups (http://buff.ly/2kcges6). In a study by Bingham C, et al evaluating immune response to vaccine in RA patients treated with tocilizumab, they found that short-term TCZ treatment did not significantly diminish humoral responses to PPSV23 (http://buff.ly/2kcbl2a).

So why did this group find that PPSV23 did not protect against pneumonia in RA patients? I see several reasons. For starters, they were looking at overall pneumonia, no just cases secondary to S. pneumonia. PPSV-23 protects against 23 serotypes of S. pneumonia, and has no protection against other pneumonia-causing bacteria. Also, their study may have been underpowered due to forced early study discontinuation because of changes in the country’s immunization recommendations.

Lastly, they did not look at immunogenicity. The current ACIP guidelines for pneumococcal vaccines in immunosuppressed patients recommend that vaccine-naïve patients should receive PCV13 (Prevnar) followed by PPSV-23 eight weeks later, followed by a booster PPSV-23 five years alter. I will continue to follow these guidelines for my RA patients.