Although the European League Against Rheumatism (EULAR) no longer takes a vaccination-for-all position for patients with rheumatic diseases, influenza vaccination should be strongly recommended by both primary care and rheumatology providers for patients with rheumatic diseases, according to an editorial published in The Lancet Rheumatology.

Patients with rheumatic diseases are at a 1.5 to 2.0-fold increased risk for hospitalization and death from complications of influenza infection. This increased risk is as a result of the underlying autoimmune disease, associated comorbidities, and treatment with immunosuppressive medications, including glucocorticoids, Janus kinase inhibitors, and disease-modifying antirheumatic drugs (DMARDs). Consequently, vaccinations are important in preventing serious infections in this high-risk population.

However, the uptake of vaccination is particularly low among patients with rheumatic diseases, with global immunization rates for patients with rheumatoid arthritis (RA) ranging between 25% and 90%, which is often below the 75% target proposed by the World Health Assembly for at-risk populations. The low uptake has largely been attributed to a perception among patients that vaccines may trigger disease flares and are ineffective, as well as a low rate of referral by clinicians.

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Because patients with rheumatic diseases have reduced ability to produce protective antibody responses, the researchers of this editorial suggest that a possible strategy may be to tweak current vaccine formulations to increase the effective dose or to make vaccines more immunogenic. Colmegna and colleagues2 demonstrated that a high-dose vs standard-dose version of the most commonly used influenza vaccine is safe and provokes increased antibody responses in patients with RA. In 2019, EULAR updated their 2011 recommendations for vaccination based on 4 systematic reviews to study the incidence of preventable infections in adult patients with autoimmune inflammatory rheumatic diseases: the efficacy, immunogenicity, and safety of vaccines in this population, the effect of antirheumatic drugs on vaccine responses, and the effect of vaccination of household members on patients. The resulting recommendations emphasized the importance of shared decision-making between patient and physician, discussing vaccination on a yearly basis, as well as encouraging vaccination when disease is dormant and before planned immunosuppression. In addition, several ongoing clinical trials are investigating how the timing of treatment might affect vaccine efficacy in patients with rheumatic diseases.


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“[T]he case remains strong that flu vaccination should be strongly advocated and recommended by both rheumatologists and [primary care providers] caring for patients with rheumatic diseases,” the researchers concluded.

References

1. Fighting flu: the importance of vaccines in rheumatic disease. Editorial.. The Lancet Rheumatology. 2020;2(2):PE63. doi:10.1016/S2665-9913(19)30161-4

2. Colmegna I, Useche ML, Rodriguez K, et al. Immunogenicity and safety of high-dose versus standard-dose inactivated influenza vaccine in rheumatoid arthritis patients: a randomised, double-blind, active-comparator trial. Lancet Rheumatol. 2020;2(1):14-23.