Public health

Plan ahead with vaccines for immunosuppressed patients

Patients with conditions such as rheumatoid arthritis are missing out on protection from vaccine-preventable diseases as doctors hesitate about vaccinating in the context of immunosuppressive drugs.

Associate Professor Peter Wong, a rheumatologist at the Mid-North Coast Arthritis Clinic and the University of NSW Rural Clinical School, said GPs and patients frequently asked about the risks of immunisation with autoimmune inflammatory rheumatic diseases.

“There are a lot of good vaccines out there and we are doing ourselves and our patients a disservice by not dealing with the issue more proactively,” he said.

A review of the evidence by Associate Professor Wong and colleagues resulted in a number of recommendations including timing and doses adjustments for vaccines such as influenza, pneumococcus, hepatitis, HPV and herpes zoster.

For example, immunocompromised patients required two initial doses of flu vaccine, four weeks apart in their first year, then annually as per the general population.

A higher dose vaccine against hepatitis B was recommended as it was more likely to induce protective antibodies than a lower dose product in patients treated with disease modifying anti-rheumatic drugs (DMARDs).

“We want this paper to encourage people to think about vaccination before significant immunosuppression or to consider stopping immunosuppressive drugs for a couple of weeks,” Associate Professor Wong told the limbic.

“Patients who are immunosuppressed don’t get the same level of protective antibodies as people who are not immunosuppressed but it is usually still enough for clinical protection,” he said.

He said live vaccines were problematic however the risk was not just for people being treated for rheumatic diseases.

“Autoimmune conditions such as rheumatoid arthritis or lupus commonly affect women during their reproductive years. They are often on the new biologics which work very well for them and they can also be pregnant or breastfeeding.”

“Depending on which biologic they are using, monoclonal antibodies can cross the placenta or be excreted in breastmilk. For that reason, it might be prudent to skip the rotavirus vaccine – the only live vaccine routinely administered to infants younger than 12 months,” he said.

Associate Professor Wong said with more patients using DMARDS and feeling well enough to travel extensively, destination-specific vaccinations should also be considered and planned well in advance.

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