High-dose flu vaccines among the immunocompromised: ‘Not just for people older than 65’
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All immunocompromised adults should receive the high-dose formulation of the influenza vaccine, according to a presenter at the Biologic Therapies Summit.
Discussing recent vaccination guideline updates from the American College of Rheumatology, Kevin L. Winthrop, MD, MPH, of the Oregon Health & Science University, stated that the new recommendations should be examined and applied while considering their nuances.
“There are several important updates, but I want to give some data behind some of the updates and get you thinking about what is next,” Winthrop, told attendees at the hybrid meeting. “Some of this is very practical and some of it is theoretical.”
The first set of guidelines Winthrop discussed included influenza vaccines, specifically that immunocompromised adults should receive high-dose versions of the influenza vaccine.
“From now on, if you are immunocompromised and an adult, you should get a high-dose vaccine,” Winthrop said. “It is not just for people older than 65.”
However, Winthrop does not recommend that all patients undergo vaccination on an annual basis in all cases.
“We kind of tricked ourselves, getting into an annual flu vaccine strategy, but it is probably ultimately not the best strategy,” Winthrop said. “You do gain a little protection every year, about 20%, but if you skip a year and you just stay home, you will do better the following year.”
Winthrop also discussed the feasibility of withholding methotrexate following vaccinations.
“The bottom line is that 1 week is good enough,” Winthrop said. “And when you look at antibody titers, they are about the same in the 1-week hold group and the 2-week hold groups.”
Additionally, the flare rate is lower among patients who withheld methotrexate for a single week, Winthrop said.
“I suspect that holding methotrexate probably helps all vaccine responses, but suffice to say, there is no data yet,” he added.
According to Winthrop, all immunocompromised patients should receive a pneumococcal vaccination. In addition, a new vaccine, Prevnar 20 (PCV 20, Pfizer), includes protection for 20 serotypes of pneumococcal infection.
“The new recommendations are, basically, to just use PCV20,” Winthrop said. “The alternate strategy is to use PCV15.”
According to Winthrop, PCV20 and PCV15 cover more strains than PCV13. In addition, if patients receive PCV15, they should typically also receive the Pneumovax (pneumococcal vaccine polyvalent, Merck) vaccination, Winthrop said.
There are currently trials evaluating PCV20 in combination with Pneumovax, he added, noting that such a combination may be recommended in the future.
Finally, he discussed Shingrix (recombinant zoster vaccine, GlaxoSmithKline) for vaccination against zoster in patients who are immunocompromised.
“Shingle prevention remains a high unmet need,” Winthrop said. “Should we be holding the JAK inhibitors? Should we hold methotrexate? There are a lot of questions around DMARDs and how we can maximize vaccine responses.”
To address this unmet need, it will be necessary to conduct more trials and gather more data, Winthrop said.
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Winthrop KL. Between the lines: The how, when and what to give of the ACR vaccine guidelines. Presented at: Biologic Therapies Summit X; May 11-13, 2023 (hybrid meeting).
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