I’ve had pneumonia, the flu, H1N1 virus, and Norovirus – it’s not a pretty picture with RA…
1. Do vaccines work as well in Rheumatoid Arthritis patients? New study shows vaccine protection may rapidly decline with anti-rheumatic drugs such as methotrexate and TNF inhibitors.
A new study published this week in Arthritis Research & Therapy showed that antibodies created by pneumococcal vaccination are reduced quickly in Rheumatoid Arthritis patients taking methotrexate or anti-TNF treatments. After a year and a half, antibody levels were close to where they were before vaccinating. It seems DMARDs (disease modifying anti-rheumatic drugs) may lessen the time that a person is protected by a vaccine. This clarifies a study from 2006 quoted by Jon Giles on the Johns Hopkins website. That study using Humira (adalimumab), demonstrated that Rheumatoid patients are able to develop immunity for influenza and pneumonia when vaccinated while taking a TNF inhibitor and a DMARD.
My first experience with vaccinations & Rheumatoid Arthritis
This past fall I was waiting to begin a new “Rheumatoid Arthritis treatment” and I realized it might be a good time to talk to the good GP about vaccinations. Every fall for the past several years, he has asked me, “Shouldn’t you get a flu shot?” Every year, I’d asked my rheumatologist whether Rheumatoid patients I should get a flu shot. The two different doctors I’d had both had said, “I don’t know.”
This year, I got the flu shot. And we scheduled an appointment for the pneumonia vaccine. But meanwhile, I did some reading and thinking. I decided to take the shingles vaccine first before starting a new disease treatment (Xeljanz) that could be considered an immunosuppressant. The pneumonia vaccine is this week, but I want to share what I’ve learned about vaccines and Rheumatoid disease treatments in case it helps another patient.
Searching for facts on “vaccinations for Rheumatoid Arthritis” Patients
Over the past couple years I’ve seen patients and rheumatologists discuss vaccinations online. Recently I read about 30 pages poking around looking for evidence to make a good decision about vaccines for flu, pneumonia, and shingles. I realized that an American College of Rheumatology (ACR) workgroup proposed increasing vaccinations of patients with rheumatic diseases. It was even more surprising that both the rheumatologists I’d asked did not recommend a flu shot. Anyway, here’s what I’ve learned:
14 more facts on safety and efficacy of vaccines in Rheumatoid Arthritis patients
2. Are Rheumatoid patients at greater risk for the shingles virus? According to the CDC (Centers for Disease Control and Prevention), the risk for zoster (shingles) is increased among persons with RA to a hazard ratio of 1.9.
3. Do RA treatments put patients at greater risk for shingles? Zoster infections might also be increased in those taking TNF-inhibitors because the immune defense against zoster is T-cell mediated, British Society for Rheumatology.
4. What is a live vaccine and does it matter? Any “live” vaccine (that contains a living weakened version of the microorganism) is not recommended for immunocompromised or immunosuppressed patients. The shingles/zoster vaccine is considered a live vaccine.
5. Which vaccines are live? The flu shot and the pneumonia shot are NOT live vaccines. Neither are the hepatitis vaccines. They are given to RA patients on DMARD or Biologic therapy. The nasal flu vaccine is considered live. Several childhood immunizations are also live such as MMR, varicella, and certain polio vaccines.
6. How long do you wait between a live vaccine and starting treatment? Cleveland Clinic recommends waiting at least 14 days, but preferably one month between a live vaccine and immunosuppressive therapy.
7. Can I be vaccinated while taking Plaquenil? Plaquenil is not considered immunosuppressive enough to avoid live vaccines, but any DMARD could alter how effective a vaccine is or how long immunity lasts.
8. Can I be vaccinated while taking Arava? Leflunomide (Arava) is a stronger immunosuppressant and live vaccines are supposed to be avoided.
9. Can I be vaccinated while taking Sulfasalazine? Sulfasalazine, like aspirin, should be avoided with live vaccines due to risk of Reye’s syndrome.
10. Can I be vaccinated while taking prednisone? The CDC considers doses over 20 mg per day of prednisone to be immunosuppressive. The recommendation is to wait one month after the dose is lowered before a live vaccine is given.
11. Can I be vaccinated while taking methotrexate? The CDC’s “Advisory Committee on Immunization Practices” does not consider low doses of azathioprine, or 6-mercaptopurine, or methotrexate (<.4 mg/kg/week) to be immunosuppressive. For several years I took 25 mg/week which means I was at .47.
12. For whom is the zoster vaccine recommended? Risk of shingles increases with age since immunity to the virus naturally wanes; therefore the zoster vaccine (Zostavax) was originally approved for over 60, but now covers over 50. My doctor warned that since I’m under 50, the vaccine cost might not be covered.
13. Which DMARDS are immunosuppressive? The British health department is more conservative with DMARDs than the CDC, calling all of the following “immunosuppressive”: methotrexate, leflunomide, azathioprine, cyclosporine, and cyclophosphamide.
14. Can I take the zoster vaccine with a Biologic? The FDA does not recommend live vaccines for people taking Biologic DMARDs. However, Jeffrey Curtis at UAB has done a large study on the zoster / shingles live vaccine in autoimmune disease patients, finding that patients on TNF inhibitors did not develop shingles from the vaccine, Arthritis Research & Therapy. In a recent update, Dr. Curtis said they found the vaccine to be effective and that the FDA should reconsider its current recommendation against its use in patients using Biologic therapies.
15. Do rheumatology leaders recommend vaccinations? Doctors are seeing the usefulness of vaccines with rheumatic disease patients: Brigham and Women’s Hospital considers increasing the pneumococcal vaccine a quality care priority. In an editorial in the Oxford Journal of Rheumatology, Dr. Thomas Gluck also urges vaccinations be increased: “So, vaccinate your immunosuppressed patients! Especially now, in the winter season, this take-home message must be regarded as most appropriate. Currently, vaccination rates are 20–35% at best. It is up to us doctors to motivate our patients to receive adequate immunization.”
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