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Vaccines should be recommended for patients treated with biologics

It is important that dermatologists routinely check patient’s immunization status before starting them on biologic therapies, according to a Markham, Ont.-based dermatologist who spoke at Dermatology Update in Toronto.

“We know that patients with different inflammatory diseases may have an increased risk of infection so to consider anything you can do to reduce the risk of those infections would be very important,” said Dr. John Kraft (left), with the Lynde Centre for Dermatology.

“Medications, as well, [such as biologics] that you add on to treat your patient with inflammatory conditions will also increase the chances of certain infections. Immunizations have their way of decreasing this infection risk.”

Patients on biologics more susceptible to infection Dr. Kraft said when clinicians are screening for cardiovascular comorbidities, latent tuberculosis or hepatitis, it it is a good opportunity to also consider immunizations.

“We are going to be putting them at a disadvantage in terms of susceptibility to getting infections. Therefore we should consider protecting them by offering vaccinations to our patients.”

Vaccines should be administered at least two weeks before biologics are started, but for a live vaccine ideally four weeks should be allotted before starting the therapy (J Rheumatol 2012:39:1583–1602).

Immunocompromised individuals who are underimmunized are vulnerable to serious infections and even death; however, healthcare providers should also consider that inappropriate administration of live vaccines can lead to serious adverse events in the immunocompromised host,” stated Dr. Claire Bombardier, professor of medicine at the University of Toronto, et al in the Journal of Rheumatology paper.

Vaccines can be either ina live or killed/inactive formand Dr. Kraft said it is criticalto find out which vaccine apat i ent i s recei vi ng andwhich brand. Another consideration is live virus shedding, noted Dr. Kraft. The probability of acquiring av accine virus after close contact with a single live attenuated influenza virus recipient is estimated at 0.58% to 2.4%.

Even though the risk is generally low, he said, “it is still worthwhile to consider isolating your immunosuppressed patient from the patient who received the live vaccine, or at

least holding off on the live vaccine in the household context of someone who is immunosuppressed.”

Tx should be stopped before adminstering live vaccine

Treatment can continue if a patient requires an inactive vaccine while on a biologic. However, Dr. Kraft said if a patient requires a live vaccine then the therapy should be stopped for two to five halflives of the biologic before the vaccine is administered.

This ranges anywhere from eight to 21 days for etanercept (4.3 mean half-life, days) to 92 to 230 days for ustekinumab (46 mean half-life, days) (J Rheumatol 2012; 39:1583–1602).

“It seems like a long time to stop the drug, but I think it is worthwhile to consider because you want to make the [live] vaccine as safe as possible when it is administered,” said Dr. Kraft.

After the vaccine is administered it is recommended to wait two to four weeks before restarting the biologic.

Dr. Kraft said some routine vaccinations to consider before starting on biologics include the influenza vaccine (yearly); pneumococcal vaccine (every three to five years); hepatitis B vaccine (vaccine if serology test is negative); diphtheria,

pertussis, and tetanus (Tdap) vaccine (every 10 years); measles, mumps, and rubella (MMR) vaccine (adult dose is live so preferably before biologic is started); and zoster vaccine (live).

Dr. Kraft said inflammatory disease patients have been found to have an increased risk of developing herpes zoster from the general population.

While the risk does not usually increase until after the age of 60 years, for some patients, such as rheumatoid arthritis or lupus patients, their risk is increased over the age of 50 years.

Other vaccines to consider include the human papillomavirus vaccine in young females and males, and vaccines for travelling patients.

Dr. Kraft said the U.S. Centers for Disease Control and Prevention’s website is a good resource tool for travellers.

It provides recommended vaccines based on the risk of those diseases in the country the patient is visiting.

Originially published in The Chronicle of Skin & Allergy (Oct/Nov. 2015; 27(7):1, 20)

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