Another possible gap in the literature relates to how rheumatic patients on these kinds of therapies may react differently to the vaccines than the general population. For example, does the suppressed immune system mean a different vaccination schedule may be required?
“Perhaps an even more important question would be, ‘How long do these vaccines last?’” says Dr. Curtis. “That is another area with a dearth of evidence. Should we adhere to the general population guidelines or do we need to give [the vaccines] more often?”
There are guidelines and suggestions in place for administering vaccinations in this group of patients. Both the ACR and the European League Against Rheumatism (EULAR) have issued official recommendations on the subject.2 Studies have shown that patients with rheumatic disease are being vaccinated at lower levels than the general population.
“With the increasing complexity of our therapeutic armamentarium for rheumatic diseases, the recommendations for vaccinations have become more complicated when compared to those who are totally healthy,” notes Leonard H. Calabrese, DO, professor of medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. “This can lead to a lack of physician confidence in knowing what their patients actually need. Studies have shown that our efficiency in vaccinating patient populations with rheumatic disease isn’t very good.”
Split Responsibilities
Some of this relates to the split responsibility for the patient. Vaccinology has long been the focus of the primary care physician. On the other hand, the medications causing the problems are in the domain of the specialty physician.
Dr. Calabrese, who is also a member of the Cleveland Clinic’s Department of Rheumatology, suggests that this is where the professional societies need to lend their weight to the discussions. It should be a collaboration between both the specialists and primary care physicians, through their organizations, to develop best practices that get the job done.
“Many questions remain unanswered [because] the necessary large and well-designed studies to confirm safety and the precise incidence of side effects have yet to be performed,” wrote Drs. Isenberg and Ferreira. “There are few studies about the effectiveness of vaccination, [because] most studies used serological responses as primary endpoints. Some may be inadequately protected because of lower vaccine immunogenicity and optimization of vaccine delivery to this specific group of patients.”
