Vaccination Guidelines for Patients With Immune-Mediated Disorders on Immunosuppressive Therapies

Abstract

Background:: Patients with immune-mediated diseases on immunosuppressive therapies have more infectious episodes than healthy individuals, yet vaccination practices by physicians for this patient population remain suboptimal.

Objectives:: To evaluate the safety and efficacy of vaccines in individuals exposed to immunosuppressive therapies and provide evidence-based clinical practice recommendations.

Methods:: A literature search for vaccination safety and efficacy in patients on immunosuppressive therapies (2009-2017) was conducted. Results were assessed using the Grading of Recommendation, Assessment, Development, and Evaluation system.

Results:: Several immunosuppressive therapies attenuate vaccine response. Thus, vaccines should be administered before treatment whenever feasible. Inactivated vaccines can be administered without treatment discontinuation. Similarly, evidence suggests that the live zoster vaccine is safe and effective while on select immunosuppressive therapy, although use of the subunit vaccine is preferred. Caution regarding other live vaccines is warranted. Drug pharmacokinetics, duration of vaccine-induced viremia, and immune response kinetics should be considered to determine appropriate timing of vaccination and treatment (re)initiation. Infants exposed to immunosuppressive therapies through breastmilk can usually be immunized according to local guidelines. Intrauterine exposure to immunosuppressive agents is not a contraindication for inactivated vaccines. Live attenuated vaccines scheduled for infants and children ⩾12 months of age, including measles, mumps, rubella, and varicella, can be safely administered as sufficient time has elapsed for drug clearance.

Conclusions:: Immunosuppressive agents may attenuate vaccine responses, but protective benefit is generally maintained. While these recommendations are evidence based, they do not replace clinical judgment, and decisions regarding vaccination must carefully assess the risks, benefits, and circumstances of individual patients.

Keywords: immune-mediated disease; immunosuppression; vaccination.

Figure 1.

Immunological targets of biologic agents.

Figure 2.

Immune pathways targeted by nonbiologic disease-modifying antirheumatic drugs.

Figure 3.

Kinetics of antibody response following immunization. The kinetics of B-cell activation and antibody (immunoglobulin M [IgM], immunoglobulin G [IgG]) production during primary and secondary responses to antigen are depicted. The primary response is characterized by a short lag phase lasting approximately 1 week, followed by the production of low-affinity IgM. IgG becomes detectable within 10 to 14 days after antigen exposure. Conversely, secondary responses reactivate memory B cells, resulting in quicker responses and higher IgG titres than those observed during a primary response.

Figure 4.

Kinetics of T-cell response. T-cell activation is initiated by the recognition of antigenic peptides displayed on the surface of antigen-presenting cells in the draining lymph nodes. This results in the clonal expansion of the activated T cell and the acquisition of effector cell function within approximately 1 week of antigen exposure. Cellular immunity plays a vital role in the clearance of intracellular pathogens and the development of robust T-cell–dependent humoral immune responses.