ACR/ARHP Annual Meeting 2012: Immunosuppressed Rheumatic Disease Patients Still Candidates for Vaccines

WASHINGTON, D.C.—People with rheumatic diseases should be considered for flu and pneumococcal vaccines—but generally not live vaccines—even if they are on immunosuppressive drugs, an expert said during a session titled, “Immunizations in Patients with Rheumatologic Disease,” here at the 2012 ACR/ARHP Annual Meeting, held November 9–14. [Editor’s Note: This session was recorded and is available via ACR SessionSelect at www.rheumatology.org.]

But since immunosuppression can impair the response to these vaccines—and evidence suggests that methotrexate may be more to blame than antitumor necrosis factor therapies alone—getting patients vaccinated early on is the best course, said Gil Melmed, MD, MS, director of clinical trials at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center in Los Angeles.

“In our diseases that we treat, immunosuppression is unpredictable,” he said, referring to autoimmune disorders. “Somebody may not be on immunosuppression now, but they may require immunosuppression tomorrow. So we have them here today, let’s take advantage of the opportunity to educate them and administer the vaccines that they should get… They may actually respond less robustly tomorrow after they are on that immunosuppressive therapy.”

Taking on an Internist Role

Rheumatologists may need to assume the role of an internist, including advising patients on getting vaccines, he said. “There are many healthcare maintenance issues that we need to think about that may not necessarily be addressed appropriately by primary care providers who usually take care of healthcare maintenance,” Dr. Melmed said.

The risk of infection in rheumatologic disease or any disease treated with immunosuppressive therapies is the most common significant adverse event that doctors have to be aware of, and many of those infections are preventable with routine vaccinations.

But patients are not getting vaccinated nearly often enough. Studies have found that only 50% to 60% of patients with rheumatic diseases on immunosuppressives are up to date on flu and pneumococcal vaccines.^1,2 One recent study found that a predictor of vaccination was a rheumatologist being in practice for fewer than 10 years.¹

At-risk patients are generally not getting their vaccines, even when they have had recent visits to a primary care physician.

Simply finding a spot in the practice flow for a brief questionnaire—and then immediately rerouting patients to receive a vaccine or at least vaccine education—can be effective in boosting vaccine rates, Dr. Melmed said. So can assigning a nonphysician vaccination coordinator.

Disease Activity in SLE

One study found that systemic lupus erythematosus (SLE) patients with no active disease had a similar response to healthy controls when given the H1N1 vaccine.³ However, those with active disease had a lower seroconversion rate; it was even worse for those with very active disease.