ACR: Varicella vaccine strongly recommended in all immunosuppressed adults
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PHILADELPHIA — The varicella vaccine is strongly recommended in all adults aged 18 years or older who are immunosuppressed, according to presenters at ACR Convergence 2022.
“This is because patients with rheumatic diseases are at a higher risk for zoster than older adults for whom vaccination has been recommended,” Clifton O. Bingham III, MD, director of the Johns Hopkins Arthritis Center, in Baltimore, told attendees.
Bingham, alongside Anne R. Bass, MD, professor of clinical medicine at the Hospital for Special Surgery and Weill Cornell Medicine, in New York, and Kevin Winthrop, MD, MPH, director of the Center for Infectious Disease Studies at Oregon Health & Science University, in Portland, presented recommendations from the newly announced ACR Guidelines for Vaccination in Patients with Rheumatic and Musculoskeletal Diseases.
According to Bass, rheumatology patients taking immunosuppressive medications may benefit from modified vaccine indications, modified vaccine schedules and/or modified medication schedules.
“Vaccination management applies across diseases,” she said.
Like most guidelines in rheumatology, the researchers used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach along with the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria.
There was a core team that drafted PICO questions, a literature review team, a patient panel and an expert voting panel. Bass highlighted the literature team as a key player, given the amount of research required for the project.
“My hat is off to them,” she said.
A broad cross-section of vaccines was included, from seasonal influenza, pneumococcus, meningococcus and HPV, to hepatitis, herpes zoster and tetanus.
Live vaccines included measles, mumps, and rubella (MMR), yellow fever, varicella, rotavirus and typhoid.
“COVID-19 vaccines were not included,” Bass said, noting that the speed with which the pandemic is evolving would have made the recommendations on the COVID-19 vaccines obsolete by the time of publication.
Before handing off to Bingham for some specific recommendations, Bass highlighted the over-arching principals the team had outlined.
“Indicated vaccines should be given whenever possible,” she said.
In addition, clinicians are encouraged to talk to their patients about their expectations and concerns.
“Shared decision-making is a key component of any vaccination strategy,” Bass said.
Regarding influenza, for patients aged 65 years and older, and those aged 18 to 65 years taking immunosuppressive medications, a high-dose adjuvanted influenza vaccination is conditionally recommended over a regular-dose vaccine, according to Bingham.
“If a high-dose or adjuvanted vaccine is unavailable, any flu vaccine is recommended over no flu vaccination,” he said.
Turning to pneumococcus, for patients aged younger than 65 years who are on immunosuppressive medication, pneumococcal vaccine is strongly recommended.
The recommendation for the HPV vaccination stipulates that patients aged older than 26 years and younger than 45 years who are taking immunosuppressive medications who previously did not receive this vaccine are conditionally recommended to get it.
“Patients on immunosuppressive therapy are at increased risk of cervical dysplasia and cervical cancer,” Bingham said.
Meanwhile, Winthrop offered an important message pertaining to disease-modifying anti-rheumatic drug (DMARD) management around the time of vaccination with non-live or live vaccines.
“We really lack a lot of data,” he said.
For example, the decision of when to withhold B-cell depleting therapies like rituximab (Rituxan, Genentech) is not clearly defined for every patient, and can be contingent on several clinical factors.
“If you can wait on rituximab dosing, do it,” Winthrop said. “If you can’t, go ahead and vaccinate.”
Meanwhile, methotrexate should be withheld for 2 weeks at the time of influenza vaccination, according to Winthrop.
However, for other DMARDs, changes to dosing are “not likely necessary” around the time of influenza vaccination, he added.
The timing of other non-live vaccines is more flexible, Winthrop said.
Lastly, he noted that tapering prednisone to a dose below 20 mg per day is likely to improve response to non-live vaccines.
“You really should vaccinate people when they are on lower doses of prednisone,” Winthrop said. “Preferably, 10 mg or below.”
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Bass AR, Bingham CO, Winthrop K. ACR Guideline for Vaccination in Patients with Rheumatic and Musculoskeletal Diseases. Presented at: ACR Convergence 2022; Nov. 11-14, 2022; Philadelphia (hybrid meeting).
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