Immunisation Guidance for Adults Treated with Immunosuppressants

Background

People with autoimmune conditions have increased susceptibility to infection due to a dysregulated immune system; the immunosuppressive medication used to treat these conditions further increases this risk of infection. It is therefore essential to offer immunisation to prevent (or at least reduce the severity of) infection.

Definition of immunosuppression

All rheumatology treatments affect the immune system, but the degree to which they impair its ability to fight infection (and control live attenuated vaccines) varies markedly. The green book defines immunosuppression as:

1. The use of cyclophosphamide within the past 6months
2. The use of biologic medication within the past 12 months
3. The use of high dose corticosteroids (>40mg prednisolone per day) for more than 1 week
4. The use of doses of prednisolone >20mg/day for more than 14 days
5. The use of methotrexate >25mg/week, azathioprine >3mg/kg/day or 6-mercaptopurine >1.5mg/kg/day.

Patients in the above category should be considered immunosuppressed and live vaccination should be avoided. We would also advise patients on ciclosporin, and mycophenolate mofetil be considered as immunosuppressed.

It is stated in the green book that patients on lower doses of corticosteroids, alone or in combination with oral immune modulating drugs at doses below those specified in points 1- 5 can, in general, receive live vaccines. There are three exceptions to this advice:

1. Yellow fever vaccine should in general be avoided, even in patients on lower dose immunomodulatory therapy
2. Shingles vaccination (see below*)
3. Rotavirus, which should be given as per schedule regardless of immunosuppression (i.e. in children exposed to TNF inhibitors in the third trimester of pregnancy).

General vaccination advice

• All patients starting on DMARDs should receive pneumovax prior to initiation if possible. If this is not possible then do not delay DMARD initiation and give pneumovax as soon as practical once DMARDs started.
• The annual inactivated flu vaccination is recommended for all patients on DMARDs.
• COVID-19 vaccination is recommended for all patients on DMARDs.

Prior to starting immunosuppressive medication

1. Inactivated vaccines should ideally be given at least 2 weeks before starting treatment
2. Live vaccines should be given at least 4 weeks before starting treatment.

For patients taking immunosuppressive medication

1. Inactivated vaccines can be given during immunosuppressive treatment but may not make a full antibody response
2. Live vaccines should NOT be given to patients taking immunosuppressive treatment or until 6 months after stopping immunosuppressive medication (or within 3 months of taking prednisolone 20mg/day for a month).

Stopping immunosuppression for the sole purpose of administering vaccines is not appropriate in the majority of cases.

COVID-19 anti-virals

Please view the COVID-19 section on the staffnet formulary for the most up to date information.

Exposure to infections

1. Patients immunised against flu via I/M injection are unlikely to develop flu symptoms from a child who has had a nasal vaccination in the same vaccination year
2. It is still possible for a patient who has been immunised to develop flu, but the risk is significantly reduced in those who have been vaccinated
3. For circumstances where patients are concerned they may have been exposed to a particular infection, please refer to the green book
4. In the specific case of chicken pox contact (at least 4 hours within the same room) in patients who are not known to be immune, please contact tay.rheumatology@nhs.scot and check VZIG status.