A Moving Target in RA: Vaccine Recommendations

Patients with rheumatic disease are under-vaccinated, but education and communication can help boost vaccination rates, according to Kevin Winthrop, M.D., Ph.D., an infectious disease epidemiologist at Oregon Health and Science University.

​Primary care physicians may be reluctant to offer vaccinations to rheumatology patients due to uncertainties about how biologic drugs that are prescribed for rheumatoid arthritis, may interact with vaccines. Also problematic, patients sometimes turn to pharmacies for routine vaccines, encountering pharmacists without access to a patient’s medical history or full knowledge about drug interactions.[[{"type":"media","view_mode":"media_crop","fid":"46377","attributes":{"alt":"©adamgregor/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_9803299279883","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5376","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©adamgregor/Shutterstock.com","typeof":"foaf:Image"}}]]

"There is some confusion about who should be giving vaccinations," Dr. Winthrop told Rheumatology Network. "Those concerns can be overcome with better education and communication between physicians." 

Improved communication between primary care physicians and rheumatologists could ensure that more patients who need vaccines get them. Electronic health records are often still clunky and inefficient, Dr. Winthrop said, but as they evolve, they could be a powerful tool for this sort of conversation. Studies show that reminders to vaccinate help improve rates.  In a presentation on vaccinations given at the American College of Rheumatology Winter Symposium in Snowmass, Colorado in January, Dr. Winthrop highlighted a

2013 study

that found a simple reminder form boosted pneumococcal vaccination rates from 67.6 percent to 80 percent in patients taking immunosuppressive medications. Vaccinations can be complex in immunocompromised patients, making rheumatologists ideal for making vaccine decisions with their patients. Rituximab, for example, severely diminishes any humoral immune response to vaccines. Some disease-modifying antirheumatic drugs (DMARDS), like methotrexate, adversely affect the Pneumovax vaccine (PPSV-23), Dr. Winthrop said. Recommendations, however, are a moving target, Dr. Winthrop said, and become quite complex depending on patient factors and immunization history. The new Prevnar-13 vaccine against pneumococcal bacteria has yet to be tested for efficacy and safety in combination with DMARDS, for example.   

Killed Vaccines

Recombinant vaccine

Live attenuated vaccine

Pneumococcal

Influenza (intramuscular)

Hepatitis B

Human Papilloma

Herpes Zoster

-      Before Initiating Therapy -

DMARD monotherapy

√

√

√

√

√

Combination DMARDs

√

√

√

√

√

TNFi biologics

√

√

√

√

√ (PICO J.1)

Non-TNF biologics

√

√

√

√

√ (PICO J.1)

-      While already taking therapy -

DMARD monotheray

√

√

√

√

√

Combination DMARDs

√

√

√

√

√

TNFi biologics

√

√

√(PICO J.4, J.5)

√

√ Not recommended (PICO J.2, J.3)

Non-TNF biologics

√

√

√ (PICO J.4, J.5)

√

√ Not recommended (PICO J.2, J.3)

_{Source:  The American College of Rheumatology, 2015 RA Treatment Recommendations}

Currently, Dr. Winthrop and his colleagues are working on an NIH-funded study on the safety and immunogenicity of the shingles vaccine (Zostavax) for patients with rheumatic illness. This population is particularly prone to shingles, Winthrop said, and it's not clear if this vaccine is safe for this group of patients.

Requirements for Shingles Live Vaccine

Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP)

and the American College of Rheumatology

Recommended in > 60 years old (ACR only)

-          Licensed > 50 years

Not contraindicated

-          MTX (<0.4 mg/kg/wk), Prednisone (<20 mg daily), azathioprine (<3.0 mg/kg/day)

Contraindicated

-          Biologics

-          Tofacitinib not specifically discussed (pre-approval)

^{Sources:  Centers for Disease Control and Prevention, Update on Herpes Zoster;  American College of Rheumatology}

References:

Perry LM, Winthrop KL, Curtis JR. 

Vaccinations for Rheumatoid Arthritis.

Curr Rheumatol Rep Current Rheumatology Reports

 2014;16(8). Desai, S. P., Lu, B., Szent-Gyorgyi, L. E., Bogdanova, A. A., Turchin, A., Weinblatt, M., Coblyn, J., Greenberg, J. O., Kachalia, A. and Solomon, D. H. (2013), 

Increasing pneumococcal vaccination for immunosuppressed patients: A cluster quality improvement trial.

Arthritis & Rheumatism

, 65: 39–47. Kevin L Winthrop, Hisashi Yamanaka, et al.

"Herpes Zoster and Tofacitinib Therapy in Patients With Rheumatoid Arthritis,"

Arthritis Rheumatology

. 2014 Oct; 66(10): 2675–2684.  Published online 2014 Sep 26. doi:  10.1002/art.38745 

Update on Herpes Zoster Vaccine: Licensure for Persons Aged 50 Through 59 Years

, Centers for Disease Control and Prevention. November 11, 2011 / 60(44);1528-1528.