LAS VEGAS – Dermatologists, like all physicians, play an important role not just in the treatment of disease, but also in the prevention of disease, and that means vaccinating patients when indicated, according to Dr. Stephen K. Tyring.
The varicella vaccines, including the chicken pox and shingles vaccines, and the human papillomavirus (HPV), hepatitis, and influenza virus vaccines are among those to consider offering to patients when appropriate, Dr. Tyring said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.
Dr. Stephen K. Tyring
Concerns arise, however, when it comes to vaccinating psoriasis patients who are – or will be – treated with biologics.
Ideally, vaccination should be offered before treatment is initiated, he said, but for some patients – such as those who are under the age for which their insurance company will cover a vaccine (age 50 or 60 for the shingles vaccine, depending on the insurance company, for example) – this may not be possible. In those already taking a biologic drug, the question is how to vaccinate safely and without interfering with treatment efficacy, he said.
"What we usually do – and there’s no absolute golden rule – is ask the patient to stop the drug for one to two half-lives of the drug," said Dr. Tyring of the University of Texas, Houston. We suggest stopping one half-life for killed, subunit, or recombinant virus vaccines and stopping for two half-lives for live attenuated virus vaccines.
With the tumor necrosis factor (TNF) inhibitor etanercept (Enbrel), for example, that means skipping one to two weekly injections.
"That’s a little bit more than a half-life, but if a patient is using Enbrel once or twice a week, the next week, instead of injecting the Enbrel, they can just come in and get the shingles vaccine [Zostavax]," he said.
Adalimumab (Humira), another anti-TNF drug, has a longer half-life, so that has to be taken into account. Things get a little more complicated when it comes to patients treated with ustekinumab (Stelera), which has a particularly long half-life, he noted.
"It’s not quite as easy, because it’s not clear how long to wait after Stelera to give a vaccine. Most efficacy is seen in the first month, and when patients come back at 3 months, they often are starting to get a little psoriasis back. Therefore, 2 months following an injection of Stelera is about the right time to get the vaccine; that way you get the minimum immunosuppression and the maximum chance to respond," he said.
Similarly, with other vaccines like the Gardasil HPV vaccine and the hepatitis A and B vaccines that require a series of shots, the biologic should be stopped for a half-life. This will mean skipping biologic dosing multiple times, but in most cases this won’t be problematic, because it typically takes about 3 months for a patient who is clear to experience significant psoriasis recurrence.
"There’s really no danger in skipping," he said.
While some may advocate waiting two half-lives after vaccination, most experts agree that is unnecessary for killed, recombinant, or subunit (for example, injectable influenza) virus vaccines but is advisable for live attenuated virus vaccines like the intranasal influenza virus vaccine or the herpes zoster vaccine Zostavax, he said.
Dr. Tyring also noted during his presentation that in his experience, concerns about increased infection risk in patients taking TNF inhibitors have been unfounded. In fact, treatment appears to provide an unexpected benefit for those who do become infected with herpes zoster: a reduced risk of postherpetic neuralgia, even among older individuals who are generally at particularly high risk.
After noticing this benefit in his own patients, Dr. Tyring asked his colleagues and found that they, too, had noticed a similar pattern. In 2011, he and his colleagues published a retrospective study of 206 patients on TNF inhibitors who developed herpes zoster, and with only two exceptions involving patients on both a TNF inhibitor and methotrexate, patients universally experienced milder symptoms if they developed shingles while on a TNF inhibitor, he said, noting that this is much lower than rates reported in the literature in the general population (J. Med. Virol. 2011;83:2051-5).
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