Vaccinations for Rheumatoid Arthritis
- 1.3k Downloads
Patients with rheumatoid arthritis (RA) suffer an increased burden of infectious disease-related morbidity and mortality and have twice the risk of acquiring a severe infection compared to the general population. This increased risk is not only a result of the autoimmune disease but is also attributed to the immunosuppressive therapies that are commonly used in this patient population. Given the increase in infection-related risks in RA, there is great interest in mitigating such risk. A number of vaccines are available to the rheumatologist, with a handful that are of importance for RA patients in the United States. The goal of this paper is to highlight the most recent literature on the key vaccines and the specific considerations for the rheumatologist and their RA patients, with a particular focus on influenza, pneumococcal, and herpes zoster vaccines. It is important for rheumatologist to understand and be aware of which vaccines are live and what potential contraindications exist for giving vaccines to RA patients.
KeywordsVaccination Rheumatoid arthritis RA Influenza Pneumococcal vaccination Herpes zoster vaccination Biologics DMARDs
Compliance with Ethics Guidelines
Conflict of Interest
Lisa Perry declares that she has no conflict of interest. Kevin Winthrop declares that he received a grant from Pfizer, consulting for Abbvie, Pfizer, UCB, Genentech. Jeffrey Curtis declares that he received consulting fees and research grants from Amgen, Abbott, BMS, Pfizer, Eli Lilly, Janssen, UCB, Roche/Genentech and CORRONA, and that he receives support from the NIH (AR064172). The authors jointly declare that this work was supported by the Agency for Healthcare Research and Quality (AHRQ) (R01HS018517).
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 6.Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res. 2012;64(5):625–39.CrossRefGoogle Scholar
- 7.Immunization Schedules: Recommended Vaccinations Indicated for Adults Based on Medical and Other Indications. 2013.Google Scholar
- 8.Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2013–2014 2013 [01/06/2014]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6207a1.htm.
- 10.•Franca IL, Ribeiro AC, Aikawa NE, Saad CG, Moraes JC, Goldstein-Schainberg C, et al. TNF blockers show distinct patterns of immune response to the pandemic influenza A H1N1 vaccine in inflammatory arthritis patients. Rheumatology. 2012;51(11):2091–8. Shows that methotrexate but not TNF blockage therapy has a deleterious effect on the influenza vaccine in RA patients.PubMedCrossRefGoogle Scholar
- 12.•Ribeiro AC, Laurindo IM, Guedes LK, Saad CG, Moraes JC, Silva CA, et al. Abatacept and reduced immune response to pandemic 2009 influenza A/H1N1 vaccination in patients with rheumatoid arthritis. Arthritis Care Res. 2013;65(3):476–80. Describes the effects of abatacept on the influenza vaccine response.CrossRefGoogle Scholar
- 15.Elkayam O, Bashkin A, Mandelboim M, Litinsky I, Comaheshter D, Levartovsky D, et al. The effect of infliximab and timing of vaccination on the humoral response to influenza vaccination in patients with rheumatoid arthritis and ankylosing spondylitis. Semin Arthritis Rheum. 2010;39(6):442–7.PubMedCrossRefGoogle Scholar
- 16.Gabay C, Bel M, Combescure C, Ribi C, Meier S, Posfay-Barbe K, et al. Impact of synthetic and biologic disease-modifying antirheumatic drugs on antibody responses to the AS03-adjuvanted pandemic influenza vaccine: a prospective, open-label, parallel-cohort, single-center study. Arthritis Rheum. 2011;63(6):1486–96.PubMedCrossRefGoogle Scholar
- 19.•Mori S, Ueki Y, Hirakata N, Oribe M, Hidaka T, Oishi K. Impact of tocilizumab therapy on antibody response to influenza vaccine in patients with rheumatoid arthritis. Ann Rheum Dis. 2012;71(12):2006–10. Evaluates the effects of tocilizumab on the influenza vaccine and pneumococcal vaccine response showing no deleterious effects.PubMedCentralPubMedCrossRefGoogle Scholar
- 22.•Rehnberg M, Brisslert M, Amu S, Zendjanchi K, Hawi G, Bokarewa MI. Vaccination response to protein and carbohydrate antigens in patients with rheumatoid arthritis after rituximab treatment. Arthritis Res Ther. 2010;12(3):R111. Describes the response to the influenza and pnemococcal vaccines as greater in patients on rituximab if given before rather than after treatment.PubMedCentralPubMedCrossRefGoogle Scholar
- 25.Kapetanovic MC, Roseman C, Jonsson G, Truedsson L, Saxne T, Geborek P. Antibody response is reduced following vaccination with 7-valent conjugate pneumococcal vaccine in adult methotrexate-treated patients with established arthritis, but not those treated with tumor necrosis factor inhibitors. Arthritis Rheum. 2011;63(12):3723–32.PubMedCrossRefGoogle Scholar
- 26.Kapetanovic MC, Roseman C, Jonsson G, Truedsson L. Heptavalent pneumococcal conjugate vaccine elicits similar antibody response as standard 23-valent polysaccharide vaccine in adult patients with RA treated with immunomodulating drugs. Clin Rheumatol. 2011;30(12):1555–61.PubMedCrossRefGoogle Scholar
- 30.•Bingham CO, 3rd, Rizzo W, Kivitz A, Hassanali A, Upmanyu R, Klearman M. Humoral immune response to vaccines in patients with rheumatoid arthritis treated with tocilizumab: results of a randomised controlled trial (VISARA). Ann Rheum Dis. 2014 Jan 21. Newest study evaluating the response to vaccines in RA patients treated with tocilizumab. Google Scholar
- 32.•Clutterbuck EA, Lazarus R, Yu LM, Bowman J, Bateman EA, Diggle L, et al. Pneumococcal conjugate and plain polysaccharide vaccines have divergent effects on antigen-specific B cells. J Infect Dis. 2012;205(9):1408–16. Explains diminished immune responses with additional vaccinations given to patients.PubMedCentralPubMedCrossRefGoogle Scholar
- 33.•Jackson LA, Gurtman A, van Cleeff M, Frenck RW, Treanor J, Jansen KU, et al. Influence of initial vaccination with 13-valent pneumococcal conjugate vaccine or 23-valent pneumococcal polysaccharide vaccine on anti-pneumococcal responses following subsequent pneumococcal vaccination in adults 50 years and older. Vaccine. 2013;31(35):3594–602. Describes that the response to the PPSV-23 vaccine might be more robust if the vaccine is given after an initial vaccination with PCV-13.PubMedCrossRefGoogle Scholar
- 34.Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine for Adults with Immunocompromising Conditions: Recommendations of the Advisory Committee on Immunization Practices (ACIP). 2012 Contract No.: 40.Google Scholar
- 36.Prevention of Herpes Zoster Recommendations of the Advisory Committee on Immunization Practices (ACIP). 2008 Contract No.: RR-5.Google Scholar
- 37.Zhang J, Delzell E, Xie F, Baddley JW, Spettell C, McMahan RM, et al. The use, safety, and effectiveness of herpes zoster vaccination in individuals with inflammatory and autoimmune diseases: a longitudinal observational study. Arthritis Res Ther. 2011;13(5):R174.PubMedCentralPubMedCrossRefGoogle Scholar
- 38.•Zhang J, Xie F, Delzell E, Chen L, Winthrop KL, Lewis JD, et al. Association between vaccination for herpes zoster and risk of herpes zoster infection among older patients with selected immune-mediated diseases. JAMA J Am Med Assoc. 2012;308(1):43–9. Describes that when the live zoster vaccine is given in the setting of current biologic use may not be associated with a short-term increase in the risk for varicella or herpes zoster.CrossRefGoogle Scholar
- 40.Yun H, Yang S, Chen L, Winthrop K, Xie F, Baddley JW, et al. Herpes Zoster Infection Across Auto-Immune and Inflammatory Dieseases: Implications for vaccination. 2014 To be presented at EULAR 2014:To be presented at EULAR 2014.Google Scholar
- 41.•Winthrop KL, Furst DE. Rheumatoid arthritis and herpes zoster: risk and prevention in those treated with anti-tumour necrosis factor therapy. Ann Rheum Dis. 2010;69(10):1735–7. Shows that there may not be an increase in the incidence of herpes zoster cases after initiation of an anti-TNF or non-biologic DMARD therapy.PubMedCrossRefGoogle Scholar
- 45.McCarthy EM, Azeez MA, Fitzpatrick FM, Donnelly S. Knowledge, attitudes, and clinical practice of rheumatologists in vaccination of the at-risk rheumatology patient population. J Clin Rheumatol Pract Rep Rheum Musculoskelet Dis. 2012;18(5):237–41.Google Scholar
- 47.Rothholz MC. The role of community pharmacies/pharmacists in vaccine delivery in the United States. Available from: http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-jun-2013/01-Pharmacies-Rothholz.pdf.