LAS VEGAS – Should live attenuated herpes zoster vaccine be administered to a 45-year-old patient with mild rheumatoid arthritis and a strong family history of autoimmune disease? Should it be administered to a patient with long-standing RA who is seropositive and taking methotrexate and prednisone?
Many physicians are justifiably concerned about whether vaccination could cause autoimmune disease, Dr. Daniel E. Furst said at the Perspectives in Rheumatic Diseases 2013 meeting.
"And there is a lot of rationale for this to happen," he said, explaining that vaccination theoretically has the potential to activate the innate immune system or cause an allergic reaction that may accelerate the immune response.
The available data "aren’t fantastic" and they tend to conflict, but they do provide some guidance, said Dr. Furst, the Carl M. Pearson Professor of Rheumatology at the University of California, Los Angeles.
A few cases of Guillain-Barré syndrome have occurred after administration of the H1N1 flu vaccine (about 1 in 100,000), and idiopathic thrombocytopenic purpura has occurred following measles, mumps, and rubella (MMR) vaccine (about 1 in 30,000), he said.
Reports regarding multiple sclerosis following hepatitis B vaccination have been conflicting.
For the first case – a 45-year-old man with a strong family history of autoimmune disease who had mild RA, with occasional wrist and knee pain but no swelling – Dr. Furst said he would tell the patient there is "very little going on there" in terms of concern about activating autoimmune disease, and he would likely provide the vaccine.
In the second case, however, it is important to consider the known increased risk of developing herpes zoster among patients with rheumatic diseases (about a twofold increased risk, largely due to prednisone use), and the risks associated with providing the vaccine – including the added risk that would come with adding a biologic to the treatment regimen.
The risk is further increased by the use of both anti–tumor necrosis factor (anti-TNF) and non–anti-TNF biologics, he said.
"It appears that anything you do to suppress the immune system increases the risk," he added.
The question is whether the benefits of vaccinating outweigh the risks. Herpes zoster vaccination is associated with about a 40% reduction in the risk of shingles in this patient population. In one retrospective study of more than 460,000 Medicare patients, about 18,000 developed herpes zoster. However, in 663 patients who were on anti-TNF therapy and who were vaccinated, none developed a disseminated case in the 42 days following vaccination.
"What this seems to suggest is that yes, you can [vaccinate]," he said. But because that evidence is from a retrospective study, he advised that if you choose to vaccinate these patients, "you better have your thoughts well organized and tell the patient there is some increased risk."
In his practice, he continues to vaccinate only before initiating biologic therapy or after a washout period.
"The evidence isn’t strong enough to change my practice," he said.
According to recommendations from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, vaccination is okay in rheumatic disease patients who are on low-dose prednisone (less than 20 mg/day) and in those on low doses of methotrexate (less than 0.4 mg/kg per week), azathioprine (less than 3.0 mg/kg per day), or 6-mercaptopurine (1.5 mg/kg per day or less), but should be avoided in transplant patients, those who have active lymphomas or HIV, and those using high-dose steroids.
The meeting was held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.
Dr. Furst reported serving as a consultant or speaker for, and/or receiving research or grant support from, AbbVie, Actelion, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Genentech/Roche, Gilead, GlaxoSmithKline, Novartis, Pfizer, and UCB. He has received grant support from the National Institutes of Health.