New AAN Guideline Backs Routine Vaccinations in MS

Megan Brooks

August 29, 2019

Patients with multiple sclerosis (MS) should receive recommended routine vaccinations, including annual influenza vaccination, an updated practice guideline from the American Academy of Neurology (AAN) concludes.

The new AAN guideline focuses specifically on vaccine-preventable infections and immunization in MS.

"Immunization status and vaccinations is a must-have conversation with MS patients, in particular to those newly diagnosed or about to start MS drugs," AAN member and guideline lead author Mauricio Farez, MD, MPH, of the FLENI Institution, Buenos Aires, Argentina, told Medscape Medical News.

"We reviewed all of the available evidence, and for people with MS, preventing infections through vaccine use is a key part of medical care. People with MS should feel safe and comfortable getting their recommended vaccinations," Farez added in a statement.

However, the guideline acknowledges that there is not enough information to say whether or not vaccinations trigger or worsen MS flares. "Still, experts in MS urge their patients to hold off on scheduling their vaccinations if they are having an MS flare simply to avoid the potential for any complications," Farez said.

The guideline, which has been endorsed by the Consortium of Multiple Sclerosis Centers and by the Multiple Sclerosis Association of America, was published online August 28 in Neurology.

Eight Recommendations

The new recommendations update the 2002 AAN guideline on immunization and MS. "Since the last guideline, several new treatments were approved for MS, the majority having an impact in one way or another on the immune response," Farez said.

"We needed to establish the evidence on those treatments and how protected our patients are with these new drugs and how to use vaccines in a smart way to prevent as much infections/complication as possible," he added.

The new guideline makes the following eight recommendations and provides a detailed rationale for each:

  1. Discuss the evidence regarding immunizations in MS with patients and explore patients' opinions, preferences, and questions (level B).

  2. Recommend that patients with MS follow all local vaccine standards, such as from the Centers for Disease Control and Prevention, the World Health Organization, and local regulatory bodies, unless there are specific contraindications (level B).

  3. Weigh local vaccine-preventable disease risks when counseling patients on vaccination (level B).

  4. Recommend that patients with MS receive the influenza vaccination annually, unless there is a specific contraindication, such as previous severe reaction (level B).

  5. Counsel patients about infection risks associated with specific immunosuppressive/immunomodulating (ISIM) medications and treatment-specific vaccination guidance according to prescribing information; vaccinate patients as needed at least 4 to 6 weeks before initiating ISIM therapy (level B); discuss the advantage of vaccination with patients as soon as possible after MS diagnosis, regardless of initial therapeutic plans, to prevent future delays in initiation of ISIM therapies (level C, based on variation in patient preferences).

  6. Screen for infections according to prescription information before initiating ISIM medications (level A) and treat patients who test positive for latent infections, including hepatitis and tuberculosis, before MS treatment, according to individual ISIM prescribing information (level B, based on feasibility and cost relative to benefit). In high-risk populations, screen for latent infections before starting ISIM therapy, even when not specifically mentioned in prescribing information (level A), and consult specialists regarding treating patients who screen positive for latent infection before treating them with ISIM medications (level B).

  7. Advise against using live-attenuated vaccines in patients with MS who are receiving ISIM therapies or who have recently discontinued these therapies (level B, based on importance of outcomes). When infection risk is high, clinicians may recommend live-attenuated vaccines if killed vaccines are unavailable for patients with MS who are currently receiving ISIM therapies (level C, based on variation in patient preferences, benefit relative to harm, and importance of outcomes).

  8. Delay vaccination in those experiencing a relapse until clinical resolution or until the relapse is no longer active (eg, the relapse is no longer progressive but may be associated with residual disability). This often occurs many weeks after relapse onset (level B).

The guideline writers note that more high-quality studies are needed to further inform recommendations.

"As more ISIM agents are developed to manage chronic diseases such as MS, long-term prospective cohort studies are required to evaluate both the safety and effectiveness of immunizations in MS," they write.

"Simultaneous prospective cohort studies to evaluate the risks of infections in patients with MS and the effect of infections on short-term and long-term disability in patients with MS will help the risk-benefit analysis of immunization in this population," they add.

The updated guideline was developed with financial support from the American Academy of Neurology. Author disclosures are listed in the original article.

Neurology. Published online August 28, 2019. Full text

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