EULAR Issues Vaccine Recommendations for Adults With AIIRD

Due to the immune dysregulation seen inpatients with autoimmune inflammatory rheumatic disease, some vaccine-preventable infections seem to be more common or more severe. Yet the immunosuppressive therapies given to these patients can blunt the vaccine efficacy or, theoretically, be associated with primary infection from certain live and attenuated vaccines. There is only a limited amount of information obtained in the controlled-trial setting to provide guidance. Hence, a structured review of published data with expert discussion is of value in helping to provide guidance as to when specific vaccination is either appropriate or should be avoided. This is a common question from our patients: "Should I get [a specific vaccine]?"

The likelihood of a patient’s getting a severe infection with a vaccine, the degree of immunosuppression, and the safety of the vaccine are all factors that rheumatologists should consider when counseling patients about vaccinations. Influenza and pneumococcal vaccine decisions are easy: Efficacy may be blunted in some settings, but the vaccines are safe and any potential efficacy would be beneficial. A decision to vaccinate patients who are about to receive rituximab must take into consideration the data that B-cell–directed therapy clearly lowers the efficacy of the vaccine, so vaccination ideally should be given prior to this therapy. This takes some planning and careful review of the patient’s vaccination history in advance.

I believe we need outcome-based trials that study clinical – not just serologic – efficacy of certain vaccines in the setting of immunosuppression. I would particularly like to see formal studies on safety and efficacy of the zoster vaccine.

Brian F. Mandell, M.D., is a rheumatologist at the Cleveland Clinic, where he holds the position of professor and acting chair in the department of medicine. Dr. Mandell has served as a consultant or speaker for Merck and Takeda Pharmaceuticals.