Vaccinations in Patients with Immune-mediated Inflammatory Diseases

Jean-François Rahier ; Michel Moutschen ; Alfons Van Gompel ; Marc Van Ranst ; Edouard Louis ; Siegfried Segaert ; Pierre Masson ; Filip De Keyser

Disclosures

Rheumatology. 2010;49(10):1815-1827. 

In This Article

Abstract and Introduction

Abstract

Patients with immune-mediated inflammatory diseases (IMID) such as RA, IBD or psoriasis, are at increased risk of infection, partially because of the disease itself, but mostly because of treatment with immunomodulatory or immunosuppressive drugs. In spite of their elevated risk for vaccine-preventable disease, vaccination coverage in IMID patients is surprisingly low. This review summarizes current literature data on vaccine safety and efficacy in IMID patients treated with immunosuppressive or immunomodulatory drugs and formulates best-practice recommendations on vaccination in this population. Especially in the current era of biological therapies, including TNF-blocking agents, special consideration should be given to vaccination strategies in IMID patients. Clinical evidence indicates that immunization of IMID patients does not increase clinical or laboratory parameters of disease activity. Live vaccines are contraindicated in immunocompromized individuals, but non-live vaccines can safely be given. Although the reduced quality of the immune response in patients under immunotherapy may have a negative impact on vaccination efficacy in this population, adequate humoral response to vaccination in IMID patients has been demonstrated for hepatitis B, influenza and pneumococcal vaccination. Vaccination status is best checked and updated before the start of immunomodulatory therapy: live vaccines are not contraindicated at that time and inactivated vaccines elicit an optimal immune response in immunocompetent individuals.

Introduction

The term immune-mediated inflammatory disease (IMID) covers a group of apparently unrelated diseases affecting various organs and systems, such as RA, IBD and psoriasis. However, these disorders share some common genetic predispositions and inflammatory pathways, characterized by cytokine dysregulation. Hence, similar anti-inflammatory treatment strategies, including administration of immunosuppressive or immunomodulatory agents (hereafter named immunotherapy), are used to treat these disorders.[1]

Vaccination is a proven and well-established strategy for prevention of infectious diseases in the general population and in patients with IMID, who have an increased risk of complications for some vaccine-preventable infections, due to both the nature of the disease and its immunomodulatory treatment. In this article, we aim (i) to summarize current scientific evidence about infection risk, vaccine safety and efficacy in patients with IMID and treatment-induced impaired immune competence and (ii) to provide clinicians with a conceptual framework and best practice recommendations on vaccine-preventable diseases in this patient population.

Literature Search and Selection

The Medline database was searched through PubMed, using the following key words, individually and in combination: 'rheumatic disease', 'psoriasis', 'inflammatory bowel disease', 'vaccine safety', 'vaccine efficacy', 'immunization', 'vaccination', 'autoimmunity', 'infection' and 'guidelines'. Additional searches included the key words mentioned above in combination with the names of specific vaccines or drugs. Additionally, the European Centre for Disease Prevention and Control, the Centers for Disease control (CDC), the British Society of Rheumatology (BSR) and the World Health Organization (WHO) web sites and publications were consulted for recent papers and recommendations regarding immunocompromized patients and immunization. The reference lists of retrieved articles were handsearched for relevant publications.

Levels of Evidence The recommendations made in this article are graded (Levels A–D) according to the classification scheme of Shekelle et al.,[2] depending on the level of evidence supporting the recommendation.

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