Vaccinations urged for rheumatic-disease patients

Many rheumatoid-disease patients are at increased risk of infection, either due to immunosuppressive drug treatment or to their underlying disease process, but surprisingly few- only 20% to 35% – receive the pneumococcal and influenza vaccinations recommended for such vulnerable patients. Dr Thomas Gluck (Klinikum der Universitat, Regensburg, Germany), in an editorial in the January 2006 issue of Rheumatology, sounded a wake-up call to rheumatologists to change this situation. “Vaccinate your immunocompromised patients!” Gluck wrote

“Rheumatologists prescribe immunosuppressive drugs in the best interest of their patients’ health. In a logical consequence, rheumatologists should also be aware of side effects associated with the immunosuppression they induce and should at least feel responsible to initiate preventive measures against infections associated with the immunosuppression,” Gluck told rheumawire. “This should be especially easy for such simple measures as recommending or administering a vaccine.”Study shows MTX but not TNF inhibitors reduce some vaccine responseGluck’s editorial was inspired by a study by Dr MC Kapetanovic (Lund University Hospital, Sweden) and colleagues that examined the influence of methotrexate (MTX), TNF inhibitors, and prednisolone on antibody responses in 149 rheumatoid arthritis (RA) patients immunized with pneumococcal polysaccharide vaccine (Pneumovax, Merck), compared with responses in 47 healthy control subjects [2]. The main study findings were that:- MTX reduced responses to vaccines, with or without TNF inhibitors – TNF inhibitors alone did not reduce vaccine response – Prednisolone did not reduce vaccine response”The reduced immune response in the MTX group suggests that a reduced responsiveness to exogenous or possibly endogenous antigens may be one of the modes of action of MTX that reduces rheumatoid inflammation,” the investigators write. There were no significant differences or trends associated with gender, age, disease duration, disease activity, anti-TNF treatment duration, MTX treatment duration and dosage, or prednisolone use and dosage among the RA patients with or without a vaccine response. Among the healthy controls, younger patients were more likely to have a vaccine response.TNF inhibitor treatment did not reduce vaccine response, and in fact responses were more common in RA patients treated with TNF inhibitors without MTX (50%) than in controls (38%).Responses of RA patients to Pneumovax vaccinationTreatment: >Twofold antibody increase (%) or , 62< TNF inhibitors without MTX: 50>, 50< TNF inhibitors with MTX: 32>, 68< MTX alone: 14>, 86< "Enhanced immune responses due to anti-TNF treatment are an interesting possibility," the authors write.In the accompanying editorial, Gluck says that this paper helps settle two concerns that have been expressed regarding vaccination of patients with RA or other rheumatoid diseases. First, these and other data show that a significant proportion of rheumatic diseases generally respond to both the pneumococcal and the influenza immunizations, although response is lower in those treated with MTX. Second, the immune responses triggered by immunization do not lead to disease flares. "Unfortunately, vaccination rates are indeed very low, not only in patients with rheumatic diseases but also in the general population - despite the evidence of considerable benefits and well-published guidelines that clearly advocate vaccination. The problem is that most patients with or without rheumatic diseases are not aware of their inappropriate vaccination status. It hurts a little bit to be vaccinated, and people tend to avoid things that hurt, especially if they don't receive an immediate benefit. What makes the problem even worse is that many doctors are also not much interested in the vaccination status of their patients," Gluck said. (Sources1) Gluck T. Vaccinate your immunocompromised patients! Rheumatology 2006; 45:9-10. 2) Kapetanovic MC, Saxne T, Sjoholm A, et al. Influence of methotrexate, TNF blockers and prednisolone on antibody responses to pneumococcal polysaccharide vaccine in patients with rheumatoid arthritis. Rheumatology 2006; 45:106-111. Rheumawire: Joint and Bone: January 2006.)