Vaccination for Patients with Rheumatic Diseases in the Era of Biologics

Sang Hoon Han

doi:10.4078/jrd.2018.25.2.100

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Han: Vaccination for Patients with Rheumatic Diseases in the Era of Biologics

Review Article

J Rheum Dis 2018;25(2):100-107.

Published online: 30 April 2018

DOI: https://doi.org/10.4078/jrd.2018.25.2.100

Vaccination for Patients with Rheumatic Diseases in the Era of Biologics

Sang Hoon Han

Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea

Corresponding to: Sang Hoon Han http://orcid.org/0000-0002-4278-5198 Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea. E-mail: shhan74@yuhs.ac

Received 9 December 201719 December 2017 Accepted 20 December 2017

This is a Open Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

A large proportion of patients with rheumatic disease have an immunocompromised status resulting from disease pathogenesis itself and/or several immunosuppressive drugs including biologics. These conditions are closely related to a higher risk of a variety of infectious diseases. Therefore, a few vaccinations for vaccine-preventable pathogens should be considered in patients with rheumatic disease at the appropriate time. The quadrivalent inactivated influenza and pneumococcal vaccinations, including both 13-valent conjugate and 23-valent polysaccharide vaccines, are strongly recommended in all patients with rheumatic disease. The immunogenicity of influenza and pneumococcal vaccination have generally been demonstrated in patients with rheumatic disease on biologics except for rituximab and abatacept. Vaccines can be administered during therapy with tumor necrosis factor-α antagonists but may be more ideal during a stable or remission status without immunosuppressive therapy. In particular, vaccination should be done at least 6 months after an injection of rituximab as a B-lymphocyte-depleting biologic. Basically, all live-attenuated vaccines should be avoided in highly immunocompromised rheumatic disease patients. The vaccination for herpes zoster (HZ) can be taken carefully according to degree of immunosuppression because the currently available vaccine is only live-attenuated. The newly developed subunit HZ vaccine is promising in immunocompromised patients with rheumatic disease.

Keywords: Vaccination, Rheumatic disease, Biologic Agents, Influenza, Pneumococcal infections, Herpes zoster

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Table 1.

The remarkable characteristics of the vaccines considering in patients with rheumatic disease [14]

Vaccines	General consideration	Precautions
Seasonal influenza	• Strongly recommended in all patients with rheumatic disease every year	• Encouragement of vaccination in people who are closely contact with patients (e.g., family members)
Inactivated	• IM or ID injection	• Rituximab can significantly reduce the efficacy
	• Quadrivalent vaccine will be more proper than trivalent	• Should be vaccinated at least 6 months after the start and 4 weeks before the next injection of rituximab
	• Can be administered during therapy with TNF-α antagonist, tocilizumab, and abatacept
	• Formulation including adjuvant can be used
Live-attenuated	• Nasal application
Live-attenuated	• Should be avoid in highly immunocompromised status
Streptococcus pneumoniae	• Strongly recommended in all patients with rheumatic disease	• Important to strictly comply the guideline for time interval between PCV13 and PPSV23 as well as time of boosting of PPSV23
	• Can be administered during therapy with TNF-α antagonist, tocilizumab, and abatacept	• PCV13 and PPSV23 should not be co-administrated
		• Should be separated at least 8 weeks between two vaccination
PCV-13	• With preventive effect for non-bacteremic pneumonia as well as IPD
PCV-13	• Induce humoral and cellular immunity
PPSV-23	• Without preventive effect for non-bacteremic pneumonia
PPSV-23	• Induce only humoral immunity
Herpes zoster		• Need to be considered for maintenance of long-term effectiveness, especially at old age of ＞80-year-old
		• Can prevent PHN as well as recurrence of HZ
Live-attenuated	• Has been used in general population
	• Should be avoid in highly immunocompromised status
Subunit	• Inactivated vaccine
	• Not approved, not available

IM: intramuscular, ID: intradermal, TNF: tumor necrosis factor, PCV: pneumococcal conjugate vaccine, PPSV: pneumococcal polysaccharide vaccine, IPD: invasive pneumococcal disease, PHN: postherpetic neuralgia, HZ: herpes zoster.

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