Vaccine Recommendations for Patients With IMIDs

At the 2022 Interdisciplinary Autoimmune Summit, Cassandra Calabrese, DO, reviewed the recommendations for vaccinations for patients with immune-mediated inflammatory diseases (IMIDs) being treated with immunosuppressive medications.

Dr Calabrese is an assistant professor of medicine at the Cleveland Clinic Lerner College of Medicine, and a rheumatologist with within the Department of Infectious Disease.

As a rule of thumb, Dr Calabrese advised, “Assess vaccine status every visit,” as it is important to keep these patients up to date on their vaccinations. Additionally, timing of vaccinations can be important for patients who are on immunosuppressive medications.

“This is a topic of increasing interest and discussion since the COVID-19 pandemic,” Dr Calabrese stated, “where we have become increasingly interested in our IMID patient population; what is the impact of our targeted therapies on response to COVID vaccines and all other vaccines?”

Consideration for when to vaccinate these patients may depend on which targeted therapy they are receiving. “We have known very well, long before the COVID vaccine, that methotrexate reduces vaccine effectiveness,” Dr Calabrese explained. In addition, she noted that “rituximab really reduces vaccine effectiveness … The strategy is to wait as long after that last rituximab cycle before vaccinating.”

Ideally, the best time to vaccinate any patient with an IMID is before the start of immunosuppressive therapy but, Dr Calabrese pointed out, “we don’t always have the opportunity to do that.”

Currently, the 2015 American College of Rheumatology (ACR) Guidelines for treatment of rheumatoid arthritis has the most recently updated guidance pertaining to vaccination. Dr Calabrese noted that “an ACR guidance document dedicated to all immunizations in rheumatic disease patients” is due to be released in the near future.

For vaccines that are nonlive, such as influenza and pneumococcal vaccines, the ideal vaccination time is “2 weeks prior to immunosuppression.” For patients on conventional synthetic and biologic disease-modifying antirheumatic drugs (DMARDs), these vaccines are fine to receive during treatment.

Live vaccines, however, should be “administered 2-4 weeks prior to immunosuppression.”

“Importantly,” Dr Calabrese noted, “there is no strong evidence of new onset autoimmune disease or significant flare of autoimmune disease after the vaccine.” However, she did point out that a small risk of gout flare in 48 hours following some vaccines, including the zoster vaccine, has been observed. “This is not something to stop you from vaccinating your patients,” Dr Calabrese said, “but something to be aware of.”

Dr Calabrese noted that patients with IMIDs are not only “at increased risk of getting the flu, [but] they’re at increased risk of having severe flu.” Additionally, immunosuppressed patients who have the flu have greater morbidity and prolonged viral shedding.

“This reiterates the importance of keeping our patients with IMIDs up-to-date with flu vaccines every year,” Dr Calabrese stated.

Vaccination to influenza is protective both serologically and clinically. “Everyone should get a flu shot,” Dr Calabrese said, adding that allergic reaction is no longer a contraindication. “Anyone with any type of egg allergy can receive flu shots.” However, she noted that those with severe egg allergy should have the vaccine administered under the care of a physician able to treat any anaphylaxis or allergic reaction.

Dr Calabrese also turned to a “practice-changing” 2019 study, which investigated whether “holding 2 doses of methotrexate after seasonal influenza vaccine in patients with well-controlled rheumatoid arthritis” could increase the vaccine effectiveness. This study found that the vaccine response was increased, though with “a slightly increased risk of flare.”

“This is something that patients should be aware of,” Dr Calabrese said. “We still have more to learn about this.”

Pneumococcal infections “remain a significant source of morbidity and mortality in immunocompromised patients,” highlighting the importance of pneumococcal vaccines. Dr Calabrese did mention that some data suggests that “patients with cryopyrin-associated autoinflammatory syndromes (CAPS) can have severe local and systemic reactions, not just after the pneumococcal polysaccharide vaccine but also after the conjugate vaccine.” While this is not a common disease, she said, this response is something to be aware of.

As Dr Calabrese explained, pneumococcal vaccine recommendations have been very complicated in the past, and “have had a big revamp very recently.” This comes on the tail of new vaccines being introduced.

In the past, the PRIME/BOOST strategy was recommended for patients with immunosuppressing conditions. This involved administering the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23) in sequence.

Currently, there are 2 new pneumococcal vaccines available: PCV15 (PCV13 + 2 additional serotypes) and PCV20 (PCV13 + 7 additional serotypes), which have come with an 2021 Pneumococcal update from the Advisory Committee on Immunization Practices (ACIP). Either of the new vaccines is recommended for:

• Immunocompetent adults ≥65 years who have not previously received a pneumococcal vaccination, or whose vaccination history is unknown; and
• Adults aged 19-64 with certain underlying medical conditions—including immunocompromising conditions—or other risk factors, who have not previously received a pneumococcal vaccination, or whose vaccination history is unknown.

Dr Calabrese noted that “if a patient receives the 20-valent vaccine, that’s the only vaccine they need. If they receive the 15-valent, that needs to be followed by a dose of PPSV23.”

The varicella zoster virus (VZV), which causes shingles, is common among immunosuppressed patients, especially those who are elderly, and is associated with substantial morbidity. Because of the number of potential complications associated with imperfect treatments, “prevention is preferable to treatment.” For example, Dr Calabrese noted, the antiviral treatment for shingles does not successfully prevent complications such as postherpetic neuralgia.”

The recombinant zoster vaccine (RZV) is a nonlive recombinant subunit vaccine that is now the recommended vaccine for VZV. Dr Calabrse noted that “there are theoretical concerns of exacerbating underlying autoimmune disease.” However, patients with autoimmune diseases and immunocompromising drugs were “like any early vaccine trials,” not included in these clinical trials.

In 2021, ACIP removed the live zoster vaccine from the immunization schedule and it is to be phased out. As of the ACIP guidance update from October 20, 2021, the RZV is recommended for all adults ≥19 years, at risk for herpes zoster because of immunodeficiency or immunosuppression due to disease or therapy. The recommended schedule is 2 doses of RZV, 2-6 months apart, regardless of past episodes of herpes zoster, or receipt of vaccine.

Dr Calabrese noted that it is important to counsel patients about reactogenicity when discussing RZV. “I do tell patients not to get this the day before a big activity or event, to expect to be down the next day,” she stated. “It’s not always the case, but I think it helps to have the expectation.”

As for COVID-19 vaccinations, the ACR has recently put out its fifth iteration of vaccination recommendations for immunocompromised patients since the start of the pandemic. Currently, the mRNA series is the preferred vaccine type, with 2 doses, followed by a third dose 28 days or more after the last dose being the schedule. Dr Calabrese noted that a fourth dose, 3 months after the third dose for patients, is now approved for patients who are immunocompromised.

Lastly, Dr Calabrese stressed the importance of counseling patients on vaccine recommendations and uptake. She noted that the recent vaccine hesitancy, especially with the COVID-19 vaccination, has been trying.  She said, “There will always be a proportion of patients who don’t respond to your guidance and information.” However, “taking just a few minutes to listen to patients, hear their concerns, inform them, and recommend and put their minds at ease,” can be incredibly persuasive to patients.

—Allison Casey

Reference:
Calabrese C. Vaccinations for patients with IMIDs: Guidelines, risks, and benefits. Presented at: Interdisciplinary Autoimmune Summit; April 23, 2022. Virtual.