Initiating Tofacitinib for RA? Vaccinate for Pneumonia First

Winthrop KL, Silverfield J, Cracewicz A, et al., The effect of tofacitinib on pneumococcal and influenza vaccine responses in rheumatoid arthritis.Ann Rheum Dis. 2015; doi:10.1136/annrheumdis-2014-207191. Online first March 21.

Response to pneumococcal vaccine may be diminished in patients just starting tofacitinib (Xeljanz) for rheumatoid arthritis (RA), especially if they’re on concomitant methotrexate (MTX), say researchers at the Oregon Health Sciences University in Portland.

At the same time, the oral Janus kinase (JAK) inhibitor appears to have little or no effect on response to seasonal influenza vaccination, judging by results of two independent studies of RA patients reported in this article. One involved patients naïve to tofacitinib, the other patients already using the drug.

Stopping tofacitinib temporarily has limited effects on response to either the influenza or the 23-valent pneumococcal polysaccharide (PPSV-23) vaccine in existing tofacitinib users, according to antibody titers, the researchers say.

In the first study, 200 RA patients taking tofacitinib for the first time were randomly assigned to placebo or 10 mg of tofacitinib twice a day, stratified by background methotrexate use. A month later, they received PPSV-23 and the 2011–2012 trivalent influenza vaccine.

The second study, among 183 patients in a drug trial extension taking either tofacitinib monotherapy or MTX combo therapy, randomized half to a two-week drug stoppag,e then vaccinated both groups one week later.

Tofacitinib patients in both trials had satisfactory responses to the flu vaccine but reduced responses to the PPSV-23 vaccine. Those also taking MTX had worse responses.

A newly available protein-conjugate vaccine for pneumococcus is recommended for patients with RA, the study authors note.

However, “current literature suggests that rheumatologists do not routinely address the need for vaccination prior to starting therapy with biologic DMARDs, and for the most part, recommended vaccines are used infrequently among patients with RA,” they comment.

The researchers conclude that it may be better to give pneumococcal vaccine prior to starting tofacitinib or methotrexate.  Patients already on tofacitinib may gain little by stopping the drug to be vaccinated.