Vaccinations in patients with immune-mediated inflammatory diseases

Abstract

Patients with immune-mediated inflammatory diseases (IMID) such as RA, IBD or psoriasis, are at increased risk of infection, partially because of the disease itself, but mostly because of treatment with immunomodulatory or immunosuppressive drugs. In spite of their elevated risk for vaccine-preventable disease, vaccination coverage in IMID patients is surprisingly low. This review summarizes current literature data on vaccine safety and efficacy in IMID patients treated with immunosuppressive or immunomodulatory drugs and formulates best-practice recommendations on vaccination in this population. Especially in the current era of biological therapies, including TNF-blocking agents, special consideration should be given to vaccination strategies in IMID patients. Clinical evidence indicates that immunization of IMID patients does not increase clinical or laboratory parameters of disease activity. Live vaccines are contraindicated in immunocompromized individuals, but non-live vaccines can safely be given. Although the reduced quality of the immune response in patients under immunotherapy may have a negative impact on vaccination efficacy in this population, adequate humoral response to vaccination in IMID patients has been demonstrated for hepatitis B, influenza and pneumococcal vaccination. Vaccination status is best checked and updated before the start of immunomodulatory therapy: live vaccines are not contraindicated at that time and inactivated vaccines elicit an optimal immune response in immunocompetent individuals.

Influenza Vaccination in Autoimmune Rheumatic Disease Patients

“…Numerous authors state similar efficiency of vaccination for RA patients and healthy volunteers, without any significant influence of DMARD's or biological therapy on the humoral response (Elkayam 2006;Rahier et al 2010). A few recent studies reported a mild or severe impairment of the humoral response after administration of biological therapy in patients suffering from RA (Gelinck et al 2008;van Assen et al 2010).…”

Effect of Methotrexate, Anti–Tumor Necrosis Factor α, and Rituximab on the Immune Response to Influenza and Pneumococcal Vaccines in Patients With Rheumatoid Arthritis: A Systematic Review and Meta‐Analysis

“…The Advisory Committee on Immunization Practices recommends that adults ages Ն19 years with immunocompromising conditions receive a dose of PCV13 followed by a dose of PPV23 at least 8 weeks later (5). Despite these recommendations, vaccination coverage in RA patients is surprisingly low (25-30%), mainly because of a lack of awareness by health care professionals and a distrust in the safety and efficacy of vaccines (6,7). Concerns about safety are not justified.…”

Septic Shock after Seasonal Influenza Vaccination in an HIV-Infected Patient during Treatment with Etanercept for Rheumatoid Arthritis: a Case Report

“…Patients with autoimmune disorders starting anti-TNF-␣ antagonists, immunomodulators, or corticosteroid drugs are at risk of a serological nonresponse, of the development of a major adverse event, or of an exacerbation of their autoimmune disease (17,18). Guidelines recommend that patients at risk for complication of influenza, including those treated with anti-TNF-␣ drugs, should be vaccinated annually against influenza (19).…”

“…Guidelines recommend that patients at risk for complication of influenza, including those treated with anti-TNF-␣ drugs, should be vaccinated annually against influenza (19). Usually, patients are required to be on a stable drug treatment before the vaccination is provided, but data on the effect of anti-TNF-␣ antagonists on immunogenicity and the response to influenza vaccination are scarce (17,18). A few recent studies reported that patients treated with anti-TNF-␣ drugs reach an adequate immunoprotective response against influenza after vaccination, although antibody titers and cellular response rates are lower than those of similar patients not treated with anti-TNF-␣ and healthy controls (20)(21)(22).…”