Altered Immunogenicity of Vaccines in RA Patients Receiving DMARDs

Vaccination rates in patients with rheumatoid arthritis (RA) remain poor “despite the high rates of infectious disease-related morbidity and mortality,” a review published in Clinical Opinion in Rheumatology has found. 

Efficacy studies on vaccination in the RA population have been limited. Some of the most common infectious complications that rheumatoid arthritis patients face are pneumonia, skin, and soft tissue infections, with some of them being vaccine preventable. Vaccine immunogenicity may be impacted by disease-modifying antirheumatic drug (DMARD) therapy; this can influence vaccine choice and timing. Researchers from Oregon Health and Science University reviewed the indications, safety, and immunogenicity of available vaccines in the setting of RA.

Findings suggest that influenza and pneumococcal vaccines are “underutilized” though they appear to be well-tolerated in rheumatoid arthritis patients and demonstrate general immunogenicity during DMARD therapy with the exception of rituximab. The intramuscular influenza vaccine is recommended to be given annually to all rheumatoid arthritis patients regardless of immunosuppressive therapy. The American College of Rheumatology (ACR) guidelines emphasize that “whenever possible, the pneumococcal vaccines should be given prior to initiation of rheumatoid arthritis therapy.”

Data regarding other non-live vaccines are not as great but hepatitis B virus (HBV) and human papillomavirus (HPV) vaccines also appear to be well-tolerated and immunogenic in the rheumatoid arthritis patient group. The HBV vaccine should be given to patients lacking natural or vaccine-induced immunity who are at risk for acquiring HBV.

Live vaccines such as those for shingles and yellow fever remain contraindicated in some patients with RA but some data suggest they may be well-tolerated in some patients. Though more prospective studies are required to further study its safety, study authors believe it is optimal to give the shingles vaccine to patients 4 weeks before starting a biologic or tofacitinib or 1 month after stopping therapy.  According to some small studies, the yellow fever vaccine may be well-tolerated in the setting of TNF blockers or corticosteroids when administered to patients with previous immunization.

Summary and Clinical Applicability

Patients with RA have increased rates of morbidity and mortality secondary to infection, with vaccinations playing an important role on disease prevention.  However, anti-rheumatic drugs have been found to alter immunogenicity, thus identifying appropriate timing and indications for specific vaccinations are critical for the practicing rheumatologist to know.

Reference

Friedman MA, Winthrop K. Vaccinations for rheumatoid arthritis. Curr Opin Rheumatol. 2016; Epub ahead of print. doi: 10.1097/BOR.0000000000000281

This article originally appeared on MPR