High-Dose Flu Vaccine Boosts Immune Response in RA Patients

Marcia Frellick

October 22, 2018

CHICAGO — A high-dose flu vaccine that is currently used for elderly patients can significantly boost the immune response of patients with rheumatoid arthritis, new data show.

There are about 1.3 million people living with rheumatoid arthritis in the United States, and they "have an increased risk of getting severe influenza," said Inés Colmegna, MD, from McGill University in Montreal.

"There is a high priority to develop new approaches to decrease this risk," she told Medscape Medical News.

Although responses were relatively low with both the high-dose trivalent inactivated influenza vaccine and the standard-dose quadrivalent inactivated influenza vaccine, they were consistently higher in patients with rheumatoid arthritis who received the high-dose vaccine, Colmegna reported here at the American College of Rheumatology 2018 Annual Meeting.

She and her colleagues assessed antibody responses in patients with seropositive rheumatoid arthritis recruited during the 2016/17 and 2017/18 flu seasons from a tertiary care center. All were at least 19 years of age (average, 61 years), and 80% were women.

In their randomized, modified double-blind, active-controlled trial, 139 patients in the high-dose group received 60 μg of hemagglutinin/strain per dose, and 140 patients in the standard-dose group received 15 μg of hemagglutinin/per strain per dose.

In logistic regression models, patients in the high-dose group were 2.8 times more likely to seroconvert to H3N2 than those in the standard-dose group (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.38 - 5.87), 2.0 times more likely to seroconvert to B/Brisbane (OR, 1.91; 95% CI, 1.15 - 3.17), and 2.3 times more likely seroconvert to H1N1 (OR, 2.33; 95% CI, 1.42 - 3.85).

Table. Rates of Seroconversion With the Two Vaccines

  High-Dose
Trivalent Vaccine
Standard-Dose
Quadrivalent Vaccine
Virus n % n %
H3N2 31 22.3 12 8.6
B/Brisbane B/Victoria lineage 62 44.6 40 28.6
A/California H1N1 36 51.4 18 25.3
A/Michigan H1N1 32 46.4 17 24.6

There was no evidence of increased rheumatoid arthritis disease activity in the month after vaccination in either of the two groups. There were also very few serious adverse events in the two groups, and all were unrelated to the vaccine.

Only vaccine dose and age were predictors of how well patients responded.

"The trial results for the high-dose flu vaccine are wonderful news for RA patients, as we now have a much more effective means for protecting our patients," said Gregg Silverman, MD, from the NYU School of Medicine in New York City.

"Now we should be sure to get the word out, and work to have 100% of our patients immunized as early in the season as possible," he told Medscape Medical News.

In addition to weakening the immune system, rheumatoid arthritis can also impair the capacity to respond to the vaccine, he pointed out.

The high-dose vaccine is produced by Sanofi and costs $60 if you buy it from Sanofi, or $80 to $100 if you buy it at a pharmacy. The standard dose costs less than $10.

But "cost-effectiveness studies done in the elderly have shown with 98% confidence that the use of the high-dose is cost-effective in the elderly," Colmegna told Medscape Medical News.

This is the first study to look at responses to the high-dose vaccine in patients with rheumatoid arthritis, she noted, adding that regulatory bodies need to approve its use in this population before rheumatologists start to switch their patients to the higher dose.

The decision of whether to switch to the higher dose will also depend on the availability of the vaccine, she said. In some parts of Canada, for instance, it is not available this season, and in some regions, other restrictions are placed on it.

Colmegna and Silverman have disclosed no relevant financial relationships.

American College of Rheumatology (ACR) 2018 Annual Meeting: Abstract 837. Presented October 21, 2018.

Follow Medscape Rheumatology on Twitter @MedscapeRheum and Marcia Frellick @mfrellick

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