October 31, 2016

Vaccines in Immunosuppressed Patients

Current guidelines and recent research

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By Elizabeth Kirchner, CNP

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In rheumatology, the vast majority of our patients have some sort of derangement of their immune system. The treatments we use to attempt to modulate their diseases almost invariably cause some degree of immunosuppression or further alteration to their innate and adaptive immune responses. This calls for both a more urgent need to prevent infectious diseases and more caution in the use and timing of immunizations. Many recommendations (e.g., flu) have remained relatively stable – with minor alterations from year to year – for decades. Others (e.g., pneumonia and shingles) have either changed over the years or have proven to be problematic for our population.

Recommendations: what’s changed?

Many recommendations regarding vaccines for immunocompromised patients have remained basically the same for many years. There have been minor tweaks to some recommendations (i.e., only the inactivated flu shot, not active flu vaccine via nasal mist; TDaP should replace Td once during an adult’s lifetime), but the overall schedule has not changed.

Vaccination against pneumococcal disease has changed significantly over the last few years. The polysaccharide vaccine recommendations have not changed, but vaccination with the conjugate was recently added to the recommendations. This has caused some confusion among rheumatology providers as well as patients. The confusion lies a little bit with the two vaccines themselves, but more often with the timing of the vaccines. Various tools, from those embedded in an EMR to the CDC smartphone app, can be extremely useful when trying to give accurate advice in a short outpatient visit.

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What needs to change

Rheumatology providers are eagerly waiting for the day when we do not have to juggle protection against herpes zoster with the risks of giving a live vaccine to patients on high-dose prednisone and/or biologic DMARDs. The VERVE trial is underway to determine the safety and efficacy of giving live Zostavax® to patients on biologics. Another option may be coming, as a study reported in 2015 that an attenuated and highly effective zoster vaccine appeared to be promising in early clinical trials. Recently a second trial studying the vaccine in older adults yielded promising results.

Kevin Winthrop, MD, MPH, of Oregon Health & Science University, will be speaking in depth about vaccination best practices in patients with immune-mediated inflammatory diseases at the upcoming Biologics VII Summit. The Summit will be held in Cleveland, Ohio at the Intercontinental Hotel and Conference Center on April 6-8, 2017. Learn more and register at www.ccfcme.org/biotherapiesVII

This activity has been approved for AMA PRA Category 1 Credit™

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Ms. Kirchner (kirchne@ccf.org; 216.445.7280) is a certified nurse practitioner in the Department of Rheumatic and Immunologic Diseases.

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