• By Ruth Jessen Hickman, MD
‘Anyone on prednisone less than 20 mg equivalent, less than 0.4mg/kg methotrexate per week or less than 6 mg/kg of azathioprine daily, can safely get a live virus vaccine.’ -Dr. Calabrese
“The issue arises in that it’s a live virus vaccine, and as rheumatologists some of our patients are on immunosuppression that might preclude them from receiving the vaccine,” says Dr. Calabrese.
“It is sometimes hard to get those kids vaccinated if they weren’t vaccinated as young children, as they should have been,” adds Dr. Winthrop. “If you’re a pediatric rheumatologist and you’ve got a 16-year-old kid with [juvenile idiopathic arthritis] that hasn’t been vaccinated previously, then you really need to try and get them vaccinated.”
The Infectious Diseases Society of America (IDSA) has made recommendations about the level of immunosuppression at which one can safety administer live virus vaccines. Dr. Calabrese points out that these recommendations are C level data, based on expert opinion. “Anyone on prednisone less than 20 mg equivalent, less than 0.4 mg/kg methotrexate per week or less than 6 mg/kg of azathioprine daily can safely get a live virus vaccine,” she says.6
Higher doses of these drugs or biologic treatments are not recommended to be given concurrently with the vaccine. Instead, a washout period is recommended, if giving the vaccine is deemed necessary. Dr. Calabrese explains, “Administration of live virus vaccines in the setting of biologic therapy is complex, and biologic therapy will need to be held both before and after vaccine administration, with the hold duration dependent on which biologic the patient is receiving.”
But you must analyze risks and benefits before removing a patient from their current treatment in order to vaccinate them. Dr. Calabrese explains this calculus will hinge on a patient/provider discussion and assessment of the patient’s risk. She says if she had a patient at low risk of contracting measles doing well on their biologic, then she would question the need to hold the drug to give an MMR vaccination at that time.
By contrast, says Dr. Calabrese, “If it were someone who is at high risk, someone around any high-risk populations, someone living in an outbreak area or planning going abroad, I would definitely think about holding their immunosuppression and vaccinating them.”
Immunosuppressed rheumatology patients can help protect themselves further by making sure their close contacts are properly vaccinated. For example, any children in their household should be vaccinated, not just for measles, but with all recommended vaccines. Says Dr. Winthrop, “My recommendation is talk to your patients about it, but it’s really to make sure they vaccinate their kids, and that their kids vaccinate their kids. This is an issue of not vaccinating young children.”
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