The ACR’s 2012 recommendations for use of DMARDs and biologic agents in treatment of rheumatoid arthritis highlighted the importance of immunizations and noted the increasing awareness of risk of preventable diseases, such as influenza and pneumonia.2 The ACR’s recommendations, such as these released by the IDSA, are in accordance with guidance from the Centers for Disease Control and Prevention.
Recommended Vaccinations
The IDSA guideline recommends several vaccines for patients with chronic inflammatory diseases:
- A combination of two vaccines is recommended against pneumonia for immunosuppressed patients: PCV13, the pneumococcal conjugate vaccine, can be administered to patients being treated with immunosuppression. At least eight weeks later, those patients should receive PPSV23, the pneumovax, followed by a second dose of PPSV23 in five years. The newer vaccine, PCV13, seems to provide greater protection against the 13 most common or virulent strains, and optimal protection is afforded with administration of both PCV13 and then PPSV23. This recommendation that the PCV13 vaccine for adults is approved for use in combination with PPSV23 is new and thus was not included in the ACR document.
- Inactivated vaccines, including influenza vaccine, can be given annually to those either being treated or about to be treated with immunosuppressive agents.
- The (live virus) varicella (VAR) vaccine can be given to patients without evidence of varicella immunity four weeks or more prior to initiation of immunosuppression. The vaccine can be considered for those who are already being treated with long-term, low-level immunosuppression. (The document defines what is meant by low- and high-level immunosuppression.)
- The zoster (ZOS) vaccine should be given to patients 60 years or older prior to initiation of immunosuppressive therapy or to those already being treated with low-dose immunosuppression. Patients 50–59 years old who are varicella positive prior to initiation of immunosuppression or who are being treated with low-dose immunosuppression can also receive the vaccine.
- The hepatitis B vaccine should not be withheld because of concerns about exacerbation of chronic immune-mediated or inflammatory illness.
Dr. Melmed noted that the IDSA guidelines reflect a “softening position” on administration of some live vaccines (varicella and zoster) that now can be given in certain circumstances, even if the patient is on immunosuppressive therapy.
“This is an evolving position which recognizes that we should not be completely dogmatic about this. We have to recognize that some infections, such as shingles or chicken pox, can be devastating to patients who are on immunosuppressive therapy and that the benefits of vaccination outweigh the theoretical risks of these specific vaccines.
