Vaccinations in patients with immune-mediated inflammatory diseases

Prevention of infection caused by immunosuppressive drugs in gastroenterology

Immunosuppressive therapy is frequently used to treat gastrointestinal diseases such as inflammatory bowel disease, autoimmune hepatitis, IgG4-related disease (autoimmune pancreatitis and sclerosing cholangitis) and in the post-transplantation setting. These drugs interfere with the immune system. The main safety concern with their use is the risk of infections. Certain infections can be prevented or their impact minimized. Physicians must adopt preventative strategies and should have a high degree of suspicion to recognize infections early and treat appropriately. This article reviews the risk factors for infections, the mechanism of action of immunosuppressive therapy and proposes preventive strategies.

Influenza vaccination in autoimmune rheumatic disease patients

Patients suffering from autoimmune rheumatic diseases have significantly higher risk of developing various infections compared to the healthy population. Our study included patients suffering from systemic lupus erythematosus (n = 30), rheumatoid arthritis (n = 37) or Sjögren's syndrome (n = 32), with stable underlying diseases status. In November 2010, 47 patients, including 35 subjects vaccinated annually during 2006-2010, received immunization against influenza with trivalent inactivated split vaccine, whereas 52 patients did not accept proposed vaccination in that period. The presence of viral (primarily influenza) and bacterial infections, parameters of disease activity (from the date of vaccination until April 2011), and titers of antibodies against A H1N1 were then monitored in vaccinated and unvaccinated patients. We have identified the importance of predisposing factors for influenza occurrence (i.e. previous respiratory infections and vaccinations in last five years, age, sex, type of disease and duration, medications, smoking) in those groups of patients. The incidence of influenza or bacterial complications (bronchitis) among vaccinated patients was significantly lower, compared to the non-vaccinated group. Importantly, there was no case of exacerbation of the underlying disease. The last vaccination in 2010 reduced the risk of influenza by 87%, but previous bacterial infections (bronchitis and pneumonia) increased influenza risk significantly. In the present study, we have shown the efficiency, sufficient immunogenicity and safety of modern influenza vaccine application in patients suffering from systemic lupus erythematosus, rheumatoid arthritis or Sjögren's syndrome.

Vaccination strategies in patients with IBD

Patients with IBD are at increased risk of infection, in part owing to the disease itself, but mostly because of treatment with immunosuppressive drugs. Although many of these infections are vaccine-preventable, vaccination coverage in patients with IBD is extremely low. The vaccine strategies examined in this Review are based on data that enable us to provide practical advice for clinicians. Clinical evidence indicates that vaccines do not increase the risk of relapse in patients with IBD. Live vaccines are contraindicated in immunocompromised individuals, but inactivated vaccines can be safely administered. Most patients receiving immunosuppressive therapy develop an immune response after vaccination, but response rates might differ from those of nonimmunosuppressed individuals. Therefore, vaccination status should be checked and updated upon diagnosis of IBD.

Immune response to influenza A/H1N1 vaccine in inflammatory bowel disease patients treated with anti TNF-α agents: effects of combined therapy with immunosuppressants

BACKGROUND AND AIMS

Our first objective was to evaluate the immune response to the adjuvanted 2009 A/H1N1 pandemic (pH1N1) vaccine in inflammatory bowel disease (IBD) patients treated with anti-TNF-α alone or combined with immunosuppressants (IS). Second and third aims were the safety of pH1N1 vaccine and the effects on IBD clinical activity.

METHODS

36 patients with Crohn's disease (CD) and 26 with ulcerative colitis (UC) and thirty-one healthy control (HC) subjects were enrolled. 47 patients were on anti TNF-α maintenance monotherapy and 15 on anti TNF-α combined with IS. Sera were collected at baseline (T0) and 4 weeks after the vaccination (T1) for antibody determination by hemagglutination inhibition (HAI). Disease activity was monitored at T0 and T1.

RESULTS

Seroprotective titers (≥1:40) in patients were comparable to HC. Seroconvertion rate (≥4 fold increase in HAI titer) was lower than HC in IBD patients (p=0.009), either on anti TNF-α monotherapy (p=0.034) or combined with IS (p=0.011). Geometric mean titer (GMT) of antibodies at T1 was significantly lower in patients on combined therapy versus those on monotherapy (p=0.0017) and versus HC (p=0.011). The factor increase of GMT at T1 versus T0 was significantly lower in IBD patients versus HC (p=0.042), and in those on combined immunosuppression, both versus monotherapy (p=0.0048) and HC (p=0.0015). None of the patients experienced a disease flare.

CONCLUSION

Our study has shown a suboptimal response to pH1N1 vaccine in IBD patients on therapy with anti TNF-α and IS compared to those on anti-TNF-α monotherapy and HC.

Immunogenecity of hepatitis A and B vaccination in pediatric patients with inflammatory bowel disease

OBJECTIVES

Aim of the study was to evaluate the response to hepatitis A and B vaccination in pediatric patients with inflammatory bowel disease (IBD).

METHODS

A total of 47 patients with IBD (25 ulcerative colitis, 14 Crohn's disease, and 8 indeterminate colitis) ages 3 to 17 years were compared with 50 healthy age- and sex-matched controls. Screening for hepatitis A and B serology was carried out before vaccination. Susceptible cases received 20 mg of recombinant DNA vaccine for hepatitis B (0, 1, and 6 months)and 720 milliELISA units of inactivated hepatitis A virus vaccine (HAV) (0 and 6 months). Postvaccination serologic evaluation was performed 1 month after the last dose of primary vaccination, 1 month after the booster dose, and once every year during follow-up.

RESULTS

A total of 23 patients and 35 controls received HAV and protective anti-HAV antibodies were developed in all of the patients and controls (P =1.00). Forty-seven patients and 50 controls received hepatitis B vaccine and 70.2% of the patients versus 90% of the controls achieved seroprotection(anti-HBs titers 10 mIU/mL) 1 month after primary vaccination (95% confidence interval 0.71–0.87, P = 0.02). The overall seroprotection rates were 96% in controls and 85.1% in patients after the whole hepatitis B vaccination series (95% confidence interval 0.83–0.95, P = 0.08). No significant reduction was observed in antibody response among patients and controls during the follow-up period.

CONCLUSIONS

The rate of seroconversion to the hepatitis B vaccine was lower in pediatric patients with IBD than in healthy controls and hepatitis A vaccine was highly immunogenic among patients with IBD.

Septic shock after seasonal influenza vaccination in an HIV-infected patient during treatment with etanercept for rheumatoid arthritis: a case report

Anti-tumor necrosis factor alpha (anti-TNF-α) is used in the treatment of rheumatic diseases not responsive to first-line regimens. Data on the safety of anti-TNF-α in HIV-infected patients are scarce and conflicting. We describe a case of septic shock and multiorgan failure that occurred after etanercept initiation and influenza vaccination in an HIV-infected woman with rheumatoid arthritis.

Kinetics of anti-hepatitis B surface antigen titers after hepatitis B vaccination in patients with inflammatory bowel disease

BACKGROUND

Clinically significant hepatitis B (HB) virus infection has been documented among immunocompromised patients who do not maintain anti-hepatitis surface antigen (anti-HBs) concentrations ≥ 10 IU/L after an adequate response to the vaccine. The aims of the study were to understand the kinetics of anti-HBs titers over time in patients with inflammatory bowel disease (IBD) who initially responded to vaccination and to identify factors predictive of losing protective anti-HBs titers.

METHODS

Patients with IBD with a response (anti-HBs > 10 IU/L at 1-3 months) to HB virus vaccination were prospectively included. Anti-HBs titers were measured at 6 and 12 months. Anti-HBs titers were considered negative if they were <10 IU/L at any time during the follow-up. The kinetics of anti-HBs titers in the long term was estimated using Kaplan-Meier curves. Cox regression analysis was performed to identify the factors predictive of losing protective anti-HBs titers.

RESULTS

The sample comprised 100 patients (mean age, 42 years; 68% Crohn's disease; 49% on thiopurines; and 14% on anti-tumor necrosis factors during follow-up). The cumulative incidence of loss of anti-HBs titers was 2% after 6 months and 15% after 12 months. The incidence rate of loss of protective anti-HBs titers was 18% per patient-year. Baseline (after vaccination) anti-HBs titers were lower among patients whose titers became negative during the follow-up than among those who maintained them >10 IU/L (191 versus 515 IU/L; P < 0.001). Treatment with anti-TNFs was the only factor associated with a higher risk of loss of anti-HBs (hazard ratio = 3.1; 95% confidence interval = 1.1-8.8; P = 0.03).

CONCLUSIONS

A high proportion of patients with IBD with protective anti-HBs titers after vaccination lose them over time (18% per patient-year of follow-up). The risk of losing protective anti-HBs titers is 3-fold higher among patients on anti- tumor necrosis factors therapy.

Factors influencing the efficacy of two injections of a pandemic 2009 influenza A (H1N1) nonadjuvanted vaccine in systemic lupus erythematosus

OBJECTIVE

To assess the factors influencing the efficacy of 2 injections of a pandemic 2009 influenza A (H1N1) vaccine in patients with systemic lupus erythematosus (SLE).

METHODS

We conducted a single-center, observational prospective study of 111 patients who were vaccinated with a monovalent, inactivated, nonadjuvanted, split-virus vaccine during December 2009 and January 2010 and received a second dose of vaccine 3 weeks later. The antibody response was evaluated using the hemagglutination inhibition assay according to the guidelines recommended for the pandemic vaccine, consisting of 3 immunogenicity criteria (i.e., a seroprotection rate of 70%, a seroconversion rate of 40%, and a geometric mean ratio [GMR] of 2.5).

RESULTS

The 3 immunogenicity criteria were met on day 42 (seroprotection rate 80.0% [95% confidence interval (95% CI) 72.5-87.5%], seroconversion rate 71.8% [95% CI 63.4-80.2%], and GMR 10.3 [95% CI 2.9-14.2]), while only 2 criteria were met on day 21 (seroprotection rate 66.7% [95% CI 57.9-75.4%], seroconversion rate 60.4% [95% CI 51.3-69.5%], and GMR 8.5 [95% CI 3.2-12.0]). The vaccine was well tolerated. Disease activity, assessed by the Safety of Estrogens in Lupus Erythematosus National Assessment version of the SLE Disease Activity Index, the British Isles Lupus Assessment Group score, and the Systemic Lupus Activity Questionnaire, did not increase. In the multivariate analysis, vaccination failure was significantly associated with immunosuppressive treatment or a lymphocyte count of ≤ 1.0 × 10⁹/liter. The second injection significantly increased the immunogenicity in these subgroups, but not high enough to fulfill the seroprotection criterion in patients receiving immunosuppressive treatment.

CONCLUSION

Our findings indicate that the efficacy of the vaccine was impaired in patients who were receiving immunosuppressive drugs or who had lymphopenia. A second injection increased vaccine immunogenicity without reaching all efficacy criteria for a pandemic vaccine in patients receiving an immunosuppressive agent. These results open possibilities for improving anti-influenza vaccination in SLE.

TNF blockers show distinct patterns of immune response to the pandemic influenza A H1N1 vaccine in inflammatory arthritis patients

OBJECTIVE

To evaluate the immunogenicity of the anti-influenza A H1N1/2009 vaccine in RA and spondyloarthritis (SpA) patients receiving distinct classes of anti-TNF agents compared with patients receiving DMARDs and healthy controls.

METHODS

One hundred and twenty patients (RA, n = 41; AS, n = 57; PsA, n = 22) on anti-TNF agents (monoclonal, n = 94; soluble receptor, n = 26) were compared with 116 inflammatory arthritis patients under DMARDs and 117 healthy controls. Seroprotection, seroconversion (SC), geometric mean titre, factor increase in geometric mean titre and adverse events were evaluated 21 days after vaccination.

RESULTS

After immunization, SC rates (58.2% vs 74.3%, P = 0.017) were significantly lower in SpA patients receiving anti-TNF therapy, whereas no difference was observed in RA patients receiving this therapy compared with healthy controls (P = 0.067). SpA patients receiving mAbs (infliximab/adalimumab) had a significantly lower SC rate compared with healthy controls (51.6% vs 74.3%, P = 0.002) or those on DMARDs (51.6% vs 74.7%, P = 0.005), whereas no difference was observed for patients on etanercept (86.7% vs 74.3%, P = 0.091). Further analysis of non-seroconverting and seroconverting SpA patients revealed that the former group had a higher mean age (P = 0.003), a higher frequency of anti-TNF (P = 0.031) and mAbs (P = 0.001) and a lower frequency of MTX (P = 0.028). In multivariate logistic regression, only older age (P = 0.015) and mAb treatment (P = 0.023) remained significant factors for non-SC in SpA patients.

CONCLUSION

This study revealed a distinct disease pattern of immune response to the pandemic influenza vaccine in inflammatory arthritis patients receiving anti-TNF agents, illustrated by a reduced immunogenicity solely in SpA patients using mAbs.

TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01151644.

Psoriasis triggered by tetanus-diphtheria vaccination

Psoriasis is a common inflammatory disease with multiple known triggers. We report the case of a patient whose psoriasis was triggered by tetanus and diphtheria immunization (Td vaccine). To the best of our knowledge, this is the first reported case of psoriasis triggered by the Td vaccine. Authors speculate about the involved mechanisms.

Management of inflammatory bowel disease in pregnancy

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) is a chronic disease affecting mainly young people in their reproductive years. IBD therefore has a major impact on patients' family planning decisions. Management of IBD in pregnancy requires a challenging balance between optimal disease control and drug safety considerations. This article aims to provide a framework for clinical decision making in IBD based on review of the literature on pregnancy-related topics.

METHODS

Medline searches with search terms 'IBD', 'Crohn's disease' or 'ulcerative colitis' in combination with keywords for the topics fertility, pregnancy, congenital abnormalities and drugs names of drugs used for treatment of IBD.

RESULTS

IBD patients have normal fertility, except for women after ileal pouch-anal anastomosis (IPAA) and men under sulfasalazine treatment. Achieving and maintaining disease remission is a key factor for successful pregnancy outcomes in this population, as active disease at conception carries an increased risk of preterm delivery and low birth weight. Clinicians should discuss the need for drug therapy to maintain remission with their patients in order to ensure therapy compliance. Most IBD drugs are compatible with pregnancy, except for methotrexate and thalidomide. If possible, anti-TNF therapy should be stopped by the end of the second trimester and the choice of delivery route should be discussed with the patient.

CONCLUSIONS

Disease control prior to conception and throughout pregnancy is the cornerstone of successful pregnancy management in IBD patients.

Acute exercise enhancement of pneumococcal vaccination response: a randomised controlled trial of weaker and stronger immune response

Acute exercise at the time of vaccination can enhance subsequent immune responses. However, the potential benefit of this effect will be its efficacy in boosting poor responses, and thus protection in at-risk populations. The current study tested the effect of exercise on the response to either a full- or half-dose Pneumococcal (Pn) vaccination to elicit stronger and weaker responses. Subjects were 133 young healthy adults, randomised to one of four groups: exercise or control task, receiving a full- or half-dose Pn vaccination. Prior to vaccination, exercise groups completed a 15 min arm and shoulder exercise task, control groups rested quietly. Antibody levels to 11 Pn strains were evaluated at baseline and 1-month. Across all participants, exercise groups showed significantly greater increase in antibody levels than control groups. When doses were compared, it emerged that those who exercised had significantly larger responses than those who rested in the half-dose group, but in the full-dose groups responses were similar. This data indicates the effectiveness of exercise as a vaccine adjuvant, particularly in weaker responses. Thus, given the potential public health benefits of no-cost behavioural intervention to enhance response to vaccination, testing in at-risk populations should be pursued.

Factors associated with 2009 monovalent H1N1 vaccine coverage: a cross sectional study of 1,308 patients with psoriasis in France

BACKGROUND

Patients with immune-mediated inflammatory diseases like psoriasis are at increased risk of infection. Specific recommendations are available regarding vaccinations however the vaccination coverage in patients with chronic inflammatory diseases has received limited attention and studies are not available in patients with psoriasis.

OBJECTIVES

To assess the coverage of 2009 monovalent H1N1 vaccination and to identify factors associated with vaccination among patients with psoriasis.

METHODS

Patients member of the French psoriasis patients association were sent a self administrated anonymous questionnaire. It consisted in socio-demographic data, history of psoriasis, seasonal and vaccination status. Factors associated with vaccination for A/H1N1 influenza were identified and adjusted odds ratios (ORa) and prevalence ratios (PRa) were estimated with their 95% confidence intervals (95% CIs) using logistic regression models.

RESULTS

1308 psoriasis patients with a mean age of 58.2 years completed the study between September and December 2010. A total of 240 (19%) patients received the 2009 monovalent H1N1 vaccine. 25 out of 75 patients treated with biologics (33%) received the vaccine. Previous influenza seasonal (ORa (PRa)=10.2 (6.6) [6.1 (4.1)-16.9 (10.7)]), pneumococcal (ORa (PRa)=2.0 (1.6) [1.2 (1.1)-3.3 (2.3)]) and hepatitis B (ORa (PRa)=2.2 (1.7) [1.4 (1.1)-3.5 (2.5)]) vaccinations were independently associated with being vaccinated for influenza A(H1N1).

CONCLUSION

This is the largest study conducted to assess the coverage of 2009 monovalent H1N1 vaccine among patients with psoriasis, a highly prevalent chronic inflammatory disease. This vaccination coverage is more than twice the one in the French general population, but still remained low for patients receiving immunosuppressants. The limited impact of specific recommendations, free vaccines and the massive national campaign warrant alternative strategies in case of future pandemics.

Canadian Rheumatology Association recommendations for the pharmacological management of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs: part II safety

OBJECTIVE

The Canadian Rheumatology Association (CRA) has developed recommendations for the pharmacological management of rheumatoid arthritis (RA) with traditional and biologic disease-modifying antirheumatic drugs (DMARD) in 2 parts. Part II, focusing on specific safety aspects of treatment with traditional and biologic DMARD in patients with RA, is reported here.

METHODS

Key questions were identified a priori based on results of a national needs-assessment survey. A systematic review of all clinical practice guidelines and consensus statements regarding treatment with traditional and biologic DMARD in patients with RA published between January 2000 and June 2010 was performed in Medline, Embase, and CINAHL databases, and was supplemented with a "grey literature" search including relevant public health guidelines. Systematic reviews of postmarketing surveillance and RA registry studies were performed to update included guideline literature reviews as appropriate. Guideline quality was independently assessed by 2 reviewers. Guideline characteristics, recommendations, and supporting evidence from observational studies and randomized trials were synthesized into evidence tables. The working group voted on recommendations using a modified Delphi technique.

RESULTS

Thirteen recommendations addressing perioperative care, screening for latent tuberculosis infection prior to the initiation of biologic DMARD, optimal vaccination practices, and treatment of RA patients with active or a history of malignancy were developed for rheumatologists, other primary prescribers of RA drug therapies, and RA patients.

CONCLUSION

These recommendations were developed based on a synthesis of international RA and public health guidelines, supporting evidence, and expert consensus in the context of the Canadian health system. They are intended to help promote best practices and improve healthcare delivery for persons with RA.

Comparison of the effectiveness of two protocols for vaccination (standard and double dosage) against hepatitis B virus in patients with inflammatory bowel disease

BACKGROUND

The response rate to hepatitis B virus (HBV) vaccination in patients with inflammatory bowel disease (IBD) is low.

AIM

To compare two vaccination protocols-the standard dose and the double dose-in IBD patients.

METHODS

Patients diagnosed with IBD from three tertiary hospitals were vaccinated against HBV with two different protocols: the standard protocol (Engerix-B single dose at 0, 1 and 6 months) and the new faster protocol based on a double dose (Engerix B double dose at 0, 1 and 2 months). Anti-HBs titres were measured 1-3 months after the last dose. A multivariate analysis was performed to identify factors that were predictive of response to the vaccine.

RESULTS

The study sample comprised 148 patients (mean age 40 years, 69% Crohn's disease), 70% of whom were receiving immunosuppressive therapy (22% thiopurines, 23% anti-TNF and 25% both). The standard protocol was followed in 46% of patients and the double dose protocol in 54%. Considering anti-HBs >10 IU/L as a successful response to vaccination, the seroconversion rate was higher among patients vaccinated with the double dose than with the standard dose: 75% (95% CI, 65-85%) vs. 41% (95% CI, 29-54%) (P < 0.001). In the multivariate analysis, vaccination with the double dose was the only factor associated with a better response to the vaccine (OR, 4; 95% CI, 2-8; P < 0.001).

CONCLUSIONS

The response rate to the HBV vaccination in IBD patients is low. Administration of a double dose was associated with a higher response rate. Therefore, the double dose protocol could be a suitable option in patients with IBD.

Effects of immunosuppression on immune response to pneumococcal vaccine in inflammatory bowel disease: a prospective study

BACKGROUND

Since immunomodulators and antitumor necrosis factor (TNF) agents are increasingly used to treat inflammatory bowel disease (IBD), it is recommended to administer antipneumococcal vaccination to prevent opportunistic pneumonia. There is some evidence that concomitant immunosuppression may impair the immune response to vaccination. We aimed to evaluate the response rates to pneumococcal vaccination in four different treatment groups (mesalamine, azathioprine, infliximab, infliximab plus azathioprine).

METHODS

In all, 96 patients with IBD (54 with Crohn's disease; 42 with ulcerative colitis) were administered a 23-valent polysaccharide pneumococcal vaccine (PSV-23). The levels of antipneumococcal antibodies were measured prior to and at least 3 weeks after vaccination. Response rates and risk factors for impaired immunosuppression were investigated. Patients on mesalamine were used as a control group.

RESULTS

Patients administered infliximab or the combination immunosuppressive therapy had significantly lower response rates to vaccination (57.6% and 62.5%, respectively) compared with the group on mesalamine (88.6%; P < 0.05 for both comparisons). Azathioprine alone did not influence the response rate to vaccination (78.9%; P = 0.43 vs. mesalamine group). Mean antibody titers after vaccination were significantly lower in patients under infliximab or combined immunosuppression than controls (P < 0.05). Immunosuppression with infliximab or combination therapy significantly decreased the likelihood of responding to vaccination (odds ratio [OR] = 0.17, 95% confidence interval [CI] 0.04-0.64, P = 0.009, and OR = 0.21, 95% CI 0.05-0.91, P = 0.038, respectively). Pneumococcal vaccination was generally safe and well tolerated.

CONCLUSIONS

Anti-TNF therapy alone or in combination with azathioprine impairs the response to pneumococcal vaccination in patients with IBD. All patients with IBD should therefore be vaccinated before starting anti-TNF therapy.

Biologic Therapy in Psoriasis: Perspectives on Associated Risks and Patient Management

Background:

Previous publications have described practical considerations for initiating biologic therapy in psoriasis patients. However, most publications have focused on anti–tumor necrosis factor (TNF) therapy.

Objective:

To create an evidence-based, practical tool that provides guidance on patient management for all biologics currently approved in Canada and the United States.

Methods:

Psoriasis publications regarding safety issues in the initiation or monitoring of adalimumab, alefacept, etanercept, infliximab, or ustekinumab therapy were identified through a PubMed search. Phase III trials and open-label extensions (regardless of indication) and relevant guidelines from Health Canada were used to compile this review.

Results:

Although these biologic agents have demonstrated efficacy in patients with psoriasis and are generally considered safe and well tolerated, rare but serious safety issues (ie, demyelination, infection, tuberculosis, malignancy, lymphoma, cardiovascular outcomes, hepatitis, pregnancy, surgery, and vaccination) have been observed. Attention to specific aspects of patient management (ie, prescreening requirements, symptoms to watch for, appropriate treatment, and referrals) is required to mitigate risk.

Conclusion:

Much of the evidence regarding the long-term safety of these agents has been based on experience in other patient populations. However, it does serve to guide us in understanding the risks that may impact the management of psoriasis patients.

Rheumatoid arthritis and anaesthesia

There has been a great deal of progress in our understanding and management of rheumatoid arthritis in recent years. The peri-operative management of rheumatoid arthritis patients can be challenging and anaesthetists need to be familiar with recent developments and potential risks of this multi system disease.

Vaccinating the inflammatory bowel disease patient: deficiencies in gastroenterologists knowledge

BACKGROUND

Current therapy for inflammatory bowel disease (IBD) patients often involves agents that suppress the immune system, placing patients at an increased risk for developing infections, of which several are potentially vaccine preventable. Many IBD patients are not being vaccinated appropriately. The aims of this study were to assess gastroenterologist's knowledge regarding vaccinating the IBD patient, eliciting the barriers that prevent vaccinations, and defining the gastroenterologist's role in vaccinations.

METHODS

One thousand gastroenterologists, randomly selected from the membership of the American College of Gastroenterology, were asked to complete a 19 question electronic survey regarding the suitable vaccines for the immunocompetent and immunosuppressed IBD patient and the barriers to recommending the vaccines. The perceived role of the gastroenterologist versus the primary care physician (PCP) was also assessed.

RESULTS

In all, 108 responses were analyzed; 68 (62%) gastroenterologists managed 40+ IBD patients, with 65 (52%) asking their patients about immunization history most or all of the time. The majority believed that the PCP should determine which vaccinations to give (64%) and to administer the vaccines (83%). Overall, 66%-88% of gastroenterologists correctly recommended the inactivated vaccines for their IBD patients not on immunosuppressive therapies while 20%-30% incorrectly recommended administering the live vaccines to their immunosuppressed patients.

CONCLUSIONS

Gastroenterologist knowledge of the appropriate immunizations to recommend to the IBD patient is poor and may be the primary reason why the majority of gastroenterologists believe that the PCP should be responsible for vaccinations. Educational programs on vaccinations directed to gastroenterologists who prescribe immunosuppressive agents are needed.

Impact of synthetic and biologic disease-modifying antirheumatic drugs on antibody responses to the AS03-adjuvanted pandemic influenza vaccine: a prospective, open-label, parallel-cohort, single-center study

OBJECTIVE

To identify the determinants of antibody responses to adjuvanted split influenza A (H1N1) vaccines in patients with inflammatory rheumatic diseases.

METHODS

One hundred seventy-three patients (82 with rheumatoid arthritis, 45 with spondylarthritis, and 46 with other inflammatory rheumatic diseases) and 138 control subjects were enrolled in this prospective single-center study. Controls received 1 dose of adjuvanted influenza A/09/H1N1 vaccine, and patients received 2 doses of the vaccine. Antibody responses were measured by hemagglutination inhibition assay before and 3-4 weeks after each dose. Geometric mean titers (GMTs) and rates of seroprotection (GMT≥40) were calculated. A comprehensive medical questionnaire was used to identify the determinants of vaccine responses and adverse events.

RESULTS

Baseline influenza A/09/H1N1 antibody levels were low in patients and controls (seroprotection rates 14.8% and 14.2%, respectively). A significant response to dose 1 was observed in both groups. However, the GMT and the seroprotection rate remained significantly lower in patients (GMT 146 versus 340, seroprotection rate 74.6% versus 87%; both P<0.001). The second dose markedly increased antibody titers in patients, with achievement of a similar GMT and seroprotection rate as elicited with a single dose in healthy controls. By multivariate regression analysis, increasing age, use of disease-modifying antirheumatic drugs (DMARDs) (except hydroxychloroquine and sulfasalazine), and recent (within 3 months) B cell depletion treatment were identified as the main determinants of vaccine responses; tumor necrosis factor α antagonist treatment was not identified as a major determinant. Immunization was well tolerated, without any adverse effect on disease activity.

CONCLUSION

DMARDs exert distinct influences on influenza vaccine responses in patients with inflammatory rheumatic diseases. Two doses of adjuvanted vaccine were necessary and sufficient to elicit responses in patients similar to those achieved with 1 dose in healthy controls.

TNF-α Antagonists and Immunization

Tumor necrosis factor (TNF) antagonists have proven to be very effective in the treatment of several autoimmune-mediated inflammatory diseases. The two classes of TNF antagonists-soluble TNF receptors and TNF monoclonal antibodies-have several important structural, pharmacokinetic, and functional differences. TNF antagonists interfere at different steps in the immune response to infections and vaccines. The immune response to pneumococcal polysaccharide vaccines is impaired in patients treated with methotrexate with some additional immunosuppressive effect of TNF antagonists. The secondary immune responses to inactivated and live attenuated vaccines, such as yellow fever vaccine, during treatment with TNF antagonists is mostly adequate despite significantly lower antibody levels. Little is known about the primary immune response to inactivated travel-related vaccines, but it is likely to be poor. Primary vaccination with live attenuated vaccines of patients receiving TNF antagonists should be avoided at all times.

Critical care of the pediatric patient with rheumatic disease

PURPOSE OF REVIEW

Extensive systemic illness and treatment with immunosuppressive agents often require patients with rheumatic diseases to be monitored or managed in the pediatric intensive care unit. Additionally, severe disease-specific manifestations of childhood rheumatic disorders present pediatric rheumatologists and critical care physicians with diagnostic and treatment challenges. Although mortality from rheumatic disease in children is rare, the most severe diseases, such as pediatric systemic lupus erythematosus and juvenile dermatomyositis, remain life-threatening.

RECENT FINDINGS

Advances in therapy have reduced the incidence of severe complications of autoimmune and inflammatory diseases and have expanded treatment options. However, patients with active underlying rheumatic disease and secondary infection who are being treated with immunosuppressive agents are most at risk for poor outcomes.

SUMMARY

Here we discuss the complications of childhood rheumatic conditions that necessitate critical intervention. We discuss how improved understanding of the cellular and molecular basis of disease pathogenesis holds the promise of more targeted therapy without the adverse effects of global immunosuppression.

Immunization in the adult immunocompromised host

The number of patients with impaired immune response has been steadily increasing within the last years, not only with the onset of the AIDS epidemic, but also due to increasing numbers of subjects on immunosuppressive therapies. These patients are at an increased risk for infections, many of which are preventable by immunization. Inactivated vaccines are generally safe in subjects with underlying immunosuppression. However, immune response and protection may be hampered, depending on the extent of immunosuppression. In contrast, live vaccines such as yellow fever, measles, rubella, herpes zoster, and cholera may lead to severe reactions in immunocompromised patients and have been shown to deteriorate some immune-mediated diseases such as multiple sclerosis. Data on the efficacy of vaccines in biological therapies is scarce. Where necessary vaccines should be updated before immunosuppressive therapies are started. To improve the vaccination status several guidelines exist for immunosuppressed patients at risk such as those with rheumatic diseases, asplenia or solid organ and hematopoietic stem cell transplantation.

Choice of Biologic Therapy for Patients with Rheumatoid Arthritis: The Infection Perspective

Biologicals revolutionized the treatment of Rheumatoid Arthritis (RA). The targeted suppression of key inflammatory pathways involved in joint inflammation and destruction allows better disease control, which, however, comes at the price of an elevated infection risk due to relative immunosuppression. The disease-related infection risk and the infection risk associated with the use of TNF-α inhibitors (infliximab, adalimumab, etanercept, golimumab and certolizumab pegol), rituximab, abatacept and tocilizumab are discussed. Risk factors clinicians need to take into account when selecting the most appropriate biologic therapy for RA patients, as well as precautions and screening concerning a number of specific infections, such as tuberculosis, intracellular bacterial infections, reactivation of chronic viral infections and HIV are reviewed.

[Vaccination under immunosuppressive therapy of chronic inflammatory diseases]

Immune-mediated inflammatory diseases and applied immunosuppressive or modulating medications predispose patients for more frequent and more severe infections. Partly, these can be prevented by vaccinations. However immunization rates in daily life are low. The indication for vaccination, the capacity of sufficient antibody response and possible adverse reactions--such as vaccination-induced infection in live-vaccines--must be carefully evaluated and timing should be planned accordingly. In addition to vaccinations according general recommendation patients with immunosuppression benefit from vaccinations against seasonal influenza and S. pneumoniae. Induction of flares of the underlying disease after vaccination could not be confirmed.