Vaccinations Should Be Part of Treatment Plans for Patients on Biologic Therapies

Systemic autoimmune rheumatic diseases often are associated with infectious complications, and the confusing array of new biologic therapies and immunomodulating medications that we use to combat these diseases can themselves promote infections. Therefore, we must proactively consider vaccinating patients before these drugs are administered.

Two experts reviewed the literature on biologics and vaccines for this patient population. The take-home points for primary care clinicians and rheumatologists follow.

— Assess patients' vaccination status before beginning any biologic agent.

— Live attenuated vaccines (e.g., herpes zoster vaccine) should be avoided in patients who are receiving biologics but can be administered to patients who are receiving <20 mg of prednisone, <0.4 mg/kg of methotrexate, or both.

— Inactivated influenza and pneumococcal vaccines are strongly recommended. Pneumococcal guidelines for immunocompromised patients include the following recommendations:

• For pneumococcal vaccine–naive adult patients, administer 13-valent pneumococcal conjugated vaccine (PCV13) first, 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 8 weeks later, and booster PPSV23 doses every 5 years.

• For patients who have already received PPSV23, administer PCV13 at least 1 year after the last PPSV23 vaccination, and booster PPSV23 doses every 5 years.

— Tetanus toxoid should be administered as in the general population.

— Responses to human papillomavirus (HPV), hepatitis A, hepatitis B, meningococcal, and Haemophilus influenzae b vaccines have not been studied in this population. The authors provide no guidance for their administration.

— Ideally, indicated vaccinations should be administered before biologics are started. If vaccines are not administered prior to beginning biologics, data support adequate response to vaccinations when patients are receiving anti–tumor necrosis factor (TNF) therapies, tocilizumab (Actemra), and probably abatacept (Orencia). Vaccines should be given before B cell–depleting therapy (rituximab [Rituxan]) or 4 to 6 months afterward.