November 10-15

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ACR Convergence 2023

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Biologics create vaccination confusion for clinicians


3 minutes

The success of biologics has created a conundrum for clinicians. Both of the diseases biologics are intended to treat and the biologics themselves can increase the risk for infection, heightening the need for appropriate vaccination practices.

As the need for more appropriate use of vaccines in patients being treated with biologics grows, so does public questioning of the need for vaccination, driven by the virtual disappearance of many infectious diseases that were once common and commonly fatal.

William Schaffner, MD

“Adult patients are largely unaware of their need for immunizations,” said William Schaffner, MD, Professor of Preventive Medicine and Infectious Diseases at Vanderbilt University School of Medicine. “Clinicians are often similarly confused or murky about immunizations and which patients should get them. And the whole issue of anti-vaccine sentiment confuses the issue even more.”

Dr. Schaffner will explore patient anxieties and concerns about vaccines during the ARHP concurrent session Vaccinations: Update and Controversies from 4:30 – 6:30 pm Sunday. David Isenberg, MD, Professor of Medicine at University College London, will explore the increasingly complex relationships between biologics and vaccinations.

“Biologics have been a paradigm shift in the treatment of the more severe rheumatic diseases, especially rheumatoid arthritis, vasculitis, psoriatic arthritis, and ankylosing spondylitis,” Dr. Isenberg said. “Biologics are being used earlier and more commonly for the simple reason that they are fantastic drugs. But there is a price to pay, and that price includes the risk of infection in patients who are taking these drugs.

David Isenberg, MD

“The increased risk is particularly evident during the first three months of treatment, particularly when you use a TNF-blocking drug or biologic. If an infection is going to occur, it tends to occur during those first 90 days of treatment. That means you need a thorough assessment of vaccination status before you begin treatment. You have to make decisions about what you will protect against with vaccination and what you won’t protect against.”

Opposition to vaccines focuses largely on pediatric vaccines, Dr. Schaffner said. And while a small core of anti-vaccine sentiment exists, parents are more often wary of vaccines than fervently opposed. In adults, the problem is usually not recognizing the need for vaccination against potentially deadly diseases such as influenza.

“We all hear adults say they never get flu or are too healthy or are worried about getting flu from vaccine,” he said. “These are urban and rural myths. Influenza is simple. Everyone over the age of six months in the United States should be vaccinated with very rare exceptions.”

Pediatric physicians are active advocates for vaccination, he said. Adult clinicians rarely promote vaccination with the same fervor. And relatively few clinicians realize that the Affordable Care Act provides coverage for adult vaccinations. Financial coverage is generally available for both adult patients and clinicians administering vaccines.

Vaccination recommendations are complex, and the addition of biologics adds to that complexity. Shingles vaccine is recommended for adults aged 60 and older, but it is a live attenuated vaccine and should not be used in patients with compromised immune function, which can include patients on biologics. Those patients, however, can get the vaccine before starting biologic therapy.

“Live attenuated vaccines should be avoided in those on 10 mg or more of prednisolone and/or immunosuppressive drugs, but we generally recommend influenza and pneumococcal vaccines in our rheumatologic patients,” Dr. Isenberg said. “Tetanus toxoid should be given as appropriate for the general population. The problem is that there are insufficient data to tell us about other vaccines, herpes zoster, for example, or Hepatitis A and B, meningococcal vaccines, BCG, and many others.”

The first step is realizing that patients can be vaccinated while on biologic therapy, even if they are taking TNF-blocking agents. Live attenuated vaccines are the potential problem area, not vaccines in general. If live attenuated vaccines are needed, they can be given before starting biologic therapy. Other types of vaccines can usually be given as recommended.