Let's discuss Vaccination with Biologic DMARDs

My rheumatologist mate, Ingrid Hutton, suggested I write this post.

I thought it best if I approached this by telling you what I do and then asking/hoping my fellow rheumatologists will add in what they do.

The reason this topic is important is that our patients who receive biologic DMARD (disease modifying anti-rheumatic drug) therapy have disturbed immune systems and will end up with a degree of increased immunosuppression on the medications.

Biologic DMARDs are used for rheumatoid arthritis, psoriatic arthritis and psoriasis, ankylosing spondylitis/spondyloarthritis and inflammatory bowel disease.

When I’m about to start patients on biologic DMARD, I suggest they have:

1) Fluvax (influenza virus vaccine). This is given yearly and should continue yearly once a patient in on the treatment. Of course, it does depend on the time of year and the proximity to flu season. While preferable to have the vaccination prior to the start of biologic DMARD therapy, the vaccine may not be available.

2) Pneumococcal vaccination. This helps prevent people from becoming infected with a particular type of bacteria called Streptococcus pneumoniae. This bacteria can cause pneumonia, sinus infections, middle ear infections, meningitis and septicaemia. It is given once and in some circumstances, it is repeated after 5 years.

What about other vaccinations while on biologic DMARDs?

Well, it’s really LIVE vaccines that must be avoided (these are attenuated, meaning the virus used is made much less virulent).

Live vaccines to avoid include:

• MMR (Measles, mumps, rubella)
• Rubella
• Rotavirus
• Varicella-Zoster
• Yellow Fever
• BCG
• Oral Typhoid

Inactivated (non-live) vaccinations are fine to have. Patients who are immunosuppressed are not more likely to have an adverse reaction. However, the worry is that the immune system might not mount as good a response to the vaccination, meaning that the vaccination is not as effective.

Vaccinations that do not have to be avoided include:

• Hepatitis A
• Hepatitis B
• HPV
• Influenza
• Rabies
• Diptheria-Tetanus
• Diptheria-Tetanus-Pertussis
• Haemophilus Influenza B
• Injectable Typhoid
• Meningococcal
• Oral Cholera
• Pneumococcal

Preparing this post made me review what I do and what I should possibly be doing. My ruminations:

• Timing can be debated. While many rheumatologists will consider vaccinations pre-commencement of biologic DMARDs, should we not be considering this with other drugs we use, such as corticosteroids especially at the higher doses eg 20mg daily. Should we consider this before starting traditional DMARDs like Methotrexate even if DMARDs like Methotrexate are not considered to be particularly immunosuppressive? Should vaccinations be optimised pre-treatment?

• Shingles occurs more commonly in our patients on immunosuppression and in particular, when corticosteroids are used. It may also occur more commonly while on biologic DMARDs. Should I be attempting to vaccinate all patients? Or those who can’t recall having had chicken pox/shingles? Or those with low antibody levels only?

• Should we aim for hepatitis B immunity in all our patients with chronic inflammatory arthritis? And if so, at what stage of management?

• Should all my younger female patients have the HPV (human papilloma virus) vaccination if not already vaccinated to prevent cervical cancer, anal cancer and genital warts? Which males do we extend this to?

• This all adds complexity and burden, as well as treatment delay to managing the patient you break the news of having a disease, for example rheumatoid arthritis, to. What is the benefit to doing all this vaccination at this earlier stage of disease, or indeed at the later stage of disease?

• And while I sit and contemplate all this, is the issue actually public and doctor awareness of vaccination? Maybe, this needs to have already been addressed to some extent at the primary health and public health levels even prior to patients ever meeting a rheumatologist.

A rather complicated topic to write about. Now over to you.

What do you think about this?

What did your rheumatologist suggest for you?

And can some of the rheumatologists reading this please contribute to the conversation?

Thanks.