When a rheumatologist is about to start a patient on treatment, it’s a good idea to consider vaccinations & think ahead, possibly holding a medication so the vaccine can be effective.
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Explore This IssueJuly 2019
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Additionally, zoster vaccinations may become more feasible for rheumatology patients, Dr. Schwartz said.
An inactivated zoster vaccine, Shingrix, is now available, making it a more appealing option for immunosuppressed patients than the live version. The original clinical trials excluded patients with autoimmune diseases and organ transplant recipients. But a recent, randomized, controlled trial tested this by enrolling 264 kidney transplant recipients, and the results suggest it is safe and effective in that population.2
Patients in the trial were on a calcineurin inhibitor, steroids and mycophenolate mofetil. Immune responses were higher among those randomized to receive the vaccine, compared with placebo. Local adverse events were higher, but renal function changes, rejections and potential immune-mediated diseases were no more common in the treatment group than in the placebo group.
“I think the signals are really showing that this may be fine and would be efficacious,” Dr. Schwartz said. “I’m really excited about this vaccine.”
He also emphasized the importance of the HPV vaccine. Immunosuppression promotes persistence of the human papillomavirus, which is linked to a variety of cancers.
“Vaccination can reduce these risks, particularly if it’s given before one acquires HPV,” he said. Dr. Schwartz recommends all rheumatology patients under the age of 27 get the HPV vaccine.
Vaccines for Travel
Traveling abroad involves extra risk for rheumatology patients who are immunosuppressed, and vaccinations to prevent illness are not always possible. The yellow fever shot, a live vaccine, is contraindicated in most patients. But an alternative is to use DEET products for protection during travel. Patients can also get a waiver if they will be in a yellow fever-prone area for just a short time, Dr. Schwartz noted.
The typhoid intramuscular vaccine is acceptable, Dr. Schwartz said, but the oral vaccine is live and should be avoided, he stressed. The hepatitis A vaccine is also recommended, and if travel is less than two weeks away, an immunoglobulin injection is recommended.
Dr. Schwartz suggested people with rheumatic diseases take copies of their prescriptions and identify ahead of time the best hospitals in the areas they’ll be visiting.
And he had one more piece of advice: “I recommend they spend the extra money to purchase evacuation insurance. If they have a complication, they can come home and get care from their doctors.”