Vaccinations for Patients with Rheumatic Diseases - RA, AS, PSA, SLE.
by Drs. David Borenstein M.D. & C.H. Weaver M.D. Executive Editors 3/2020
Rheumatic disease patients including those with rheumatoid arthritis and ankylosing spondylitis are at risk for infections compared to a normal population of people. In addition to their underlying disease, some of the therapies used for these conditions [disease-modifying drugs (DMARDs) and biologics] may also increase the risk of infection.
Vaccinations are a well-established means of decreasing the risk of certain infections. However, the characteristics of the vaccine (live versus dead) and the medicines a patient is taking can have an effect on whether the vaccine will be effective. Modification of the immune response by DMARDs and biologics can minimize the booster effect of the vaccine. The timing of administration is also important in getting the maximum benefit.
The 2019 novel coronavirus (2019-nCoV) is a new virus that causes respiratory illness in people and can spread from person-to-person. This virus was first identified during an investigation into an outbreak in Wuhan, China and has quickly spread throughout China and to 31 other countries including the United States. Individuals with weakened immune systems such as patients on immunosuppressive medications for the treatment of Rheumatoid Arthritis, Psoriatic Arthritis or Ankylosing Spondylitis might be at higher risk for infection and complications associated with the virus that causes COVID illness. There is currently no vaccine but one is in development.
Vaccine Progress: There are ~ 70 vaccines in various stages of development, most in pre-clinical trials (animal studies to assess immune response), and there are three vaccines currently in clinical human trials, with initial results expected late Summer or early Fall:
- Moderna (Cambridge, MA): This was the first vaccine to be studied in humans with the first person receiving it in Seattle in March.
- Inovio Pharmaceuticals (San Diego CA): One trial is underway at the University of Pennsylvania and a second trial of their vaccine is about to begin in South Korea.
- CanSino Biological (Wuhan, China): Phase 1 completed in March, Phase 2 starting in April to look for adverse response and for antibody responses
Influenza is a seasonal viral infection that commonly occurs during the winter months beginning in November.
Influenza is an inactivated virus vaccine that is appropriate for all rheumatology patients to receive annually. The high dose flu vaccine does offer greater protective amounts of anti-influenza antibodies than standard dose. The guess every year is the type of influenza virus that is included in the vaccine. Different strains are included each year. Some years work better than others. For example, in 2020, the influenza vaccine was 50% effective.
Methotrexate is a DMARD that is used to treat rheumatoid arthritis and spondyloarthritis. This drug can blunt the response to vaccines. That is the case with influenza vaccine. It is recommended that methotrexate be stopped for 2 weeks after the vaccine is administered in order to receive optimal benefit.
Pneumococcal bacteria can cause pneumonia and other infections. Optimal vaccination against pneumococcal disease consists of the Pneumovax and Prevnar vaccine. Vaccination is appropriate for all individuals with chronic diseases and adults over 65 years of age.
The Prevnair vaccine is helpful for preventing pneumococcal community-acquired pneumonia Prevnair is usually given first followed by Pneumovax 1 year later. Similar to the influenza vaccine, methotrexate needs to be stopped for 2 weeks after the inoculation. Anti-tumor necrosis factor biologic medications do not need to be discontinued. Other biologics like rituximab and Janus Kinase inhibitors need to be stopped.
Chickenpox is a viral infection that was common in children before a vaccine was developed to prevent the illness. Individuals who were exposed to chickenpox are at risk of a reemergence of the virus. This reemergence is called herpes zoster or “shingles.” Shingles causes a painful rash that usually develops in a single stripe on one side of the body or face. The condition can affect anyone who’s had chickenpox but is most common in older people or those with a weakened immune system. People with immune-mediated conditions such as RA are also at increased risk of shingles.
The U.S. Food and Drug Administration (FDA) has approved two vaccines to prevent shingles: Zostavax and Shingrix. Zostavax is a live vaccine. This means it contains a weakened form of the virus. Shingrix vaccine is a recombinant vaccine. This means vaccine manufacturers created it by altering and purifying DNA that codes for an antigen to produce an immune response to fight the virus. The Shingrix vaccine as the preferred option whenever possible. Shingrix is more effective and likely longer lasting than the Zostavax vaccine in preventing shingles. effective in preventing postherpetic neuralgia. Patients should discuss the role of the “shingles” vaccine with their physician.