Effect of Antirheumatic Drugs on Vaccines
The Sousa review identified an overall pattern indicating that the immune activity of most vaccines was largely unaffected by treatment with glucocorticoids and conventional disease-modifying antirheumatic drugs.2
One particular exception was the use of tumor necrosis factor-inhibiting agents, which resulted in lower antibody responses to numerous vaccines, including those for pneumococcus, influenza, meningococcal C, and hepatitis A.2 This contrasted with the findings of the EULAR task force, which determined that anti-tumor necrosis factor α therapies were not shown to reduce responses in most studies.4
In addition, the EULAR task force4 found that:
- Nonlive vaccines were deemed safe while using glucocorticosteroids at doses of 2.5-40 mg/day, methotrexate 7-25 mg/week, other disease-modifying antirheumatic drugs such as azathioprine, or biological agents.
- Although the evidence was limited, administering live-attenuated booster vaccines was also found to be safe in patients receiving regular methotrexate dosages, low-dose glucocorticosteroids, and anti-tumor necrosis factor α therapy. It was generally determined that boosters may be given when essential. The explanation for this was that primary vaccines are generally scheduled in early childhood, before the development of most ARDs, and therefore, booster doses are less likely to interact with high-dose immunosuppressive drugs and biological agents.
- Studies on live-attenuated vaccines that have been conducted usually evaluated only patients receiving low-dose disease-modifying antirheumatic drug or glucocorticosteroid therapies, with “reassuring” results on safety.
- In patients receiving high-dose therapies (azathioprine, glucocorticoids), immunogenic responses to vaccines for influenza and varicella zoster virus
- Rituximab reduced responses to both T-cell-independent and T-cell-dependent vaccines.
The general recommendation to overcome these interaction challenges was to vaccinate before initiation of immunosuppressive drug therapies. Laboratory testing to determine antibody titers for these patients may also help identify optimal timing of vaccines.
Although much study is still needed, several literature reviews have indicated vaccines should be considered for pediatric patients with rheumatic diseases, with specific evaluations in each case. In particular, vaccines for influenza and pneumococcus were found in the majority of studies to be both safe and effective in these populations.
- Papadopoulou D, Sipsas NV. Comparison of national clinical practice guidelines and recommendations on vaccination of adult patients with autoimmune rheumatic diseases. Rheumatol Int. 2014;34(2):151-163.
- Sousa S, Duarte AC, Cordiero F, et al. Efficacy and safety of vaccination in pediatric patients with systemic inflammatory rheumatic diseases: a systematic review of the literature. Acta Rheumatol Port. 2017;42:8-16.
- Lopez A, Mariette X, Bachelez H, et al. Vaccination recommendations for the adult immunosuppressed patient: A systematic review and comprehensive field synopsis. J Autoimmun 2017;80:10-27.
- Heijstek MW, Ott de Bruin LM, Bijl M, et al. EULAR recommendations for vaccination in paediatric patients with rheumatic diseases. Ann Rheum Dis. 2011;70:1704-1712.
- BSR Clinical Affairs Committee. Vaccinations in the Immunocompromised Person: Guidelines for the Patient Taking Immunosuppressants, Steroids and the New Biologic Therapies. London: British Society for Rheumatology; 2002.
- Kroger AT, Atkinson WL, Marcuse EK, et al. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55:1-48.