Report: Vaccinating While On Biologics Requires Special Care

Doctors treating people with psoriasis and psoriatic arthritis should advise patients carefully about vaccines before starting on treatments that suppress the immune system, like biologics, said Dr. Abby Van Voorhees, National Psoriasis Foundation Medical Board member and co-author of a report recently published in the Journal of the American Academy of Dermatology.

Keeping up-to-date with routine vaccinations would protect people with psoriasis whose immune systems have been suppressed by biologic drugs. However, according to the report, many adults with psoriasis are behind on vaccinations.

At the same time, vaccination itself may pose a danger if a patient is under treatment.

The Medical Board's report makes specific recommendations for routine vaccines based on whether the patient is taking a systemic drug that suppresses the immune system, and calls for further study into the safety and effectiveness of specific vaccines in people with compromised immunity.

Biologic drugs treat psoriasis by blocking some of the immune system processes that create psoriasis inflammation. While biologics often improve the disease for people with psoriasis and psoriatic arthritis, they also interfere with parts of the immune system that fight off infection.

According to the report, those vaccines that are based on so-called "inactivated" viruses are safe for biologic users. These viruses have been thoroughly maimed with heat, chemicals or radiation, and they are the basis for the common diphtheria-tetanus-pertussis vaccine, for example. Yet even while safe, they have not necessarily proven to be effective for these patients, according to the report. Because less is known about impact of "live virus" vaccines -- such the measles-mumps-rubella vaccine – physicians and their psoriasis and psoriatic arthritis patients should not assume those vaccines are safe.

Citing the need for more careful study, many of the report's recommendations remain tentative. Nevertheless, they are specific and highly pertinent: For example, people traveling to Africa and South America will be asked to be vaccinated against yellow fever. This is "not recommended" for those taking any of the common class of biologic drugs in combination with cyclosporine, as many do. The yellow fever is a live-virus vaccine. The report recommends also when patient' family members should and should not be vaccinated.

Following are the routine vaccination recommendations:

VaccineBefore systemic therapyOn systemic therapy
Flu Vaccinate with either live or inactivated vaccine Vaccinate yearly with inactivated vaccine
Chicken pox Test for immunity; if negative, offer vaccine Not recommended in most cases. Discuss with physician.
Zoster 1 dose for adults under 50 Not recommended, however, limited data from one study suggests it may be feasible.
HPV Recommended for males and females up to age 26 Recommended for males and females up to age 26
Hepatitis A Vaccinate if at high risk Vaccinate if at high risk, consider verifying immunization afterward
Hepatitis B Vaccinate if tests show no disease or immunity and if risk factors are present Use high-dose vaccine, consider verifying immunization afterward
Pneumococcal Recommended, but precede with PPSV23 vaccination Vaccinate first with PCV13, then PPSV23
Hib Vaccinate unvaccinated adults Vaccinate unvaccinated adults
Measles-mumps-rubella Vaccinate if no history of disease and tests show no immunity Not recommended in most cases. Discuss with physician.
Tetanus-diptheria-pertussis If wounds are high-risk and patient has had no pertussis vaccination, vaccinate with Tdap, provided last Td vaccination was more than two years prior. Booster dose if more than 10 years prior. If wounds are high-risk and patient has had no pertussis vaccination, vaccinate with Tdap, provided last Td vaccination was more than two years prior. Booster dose if more than ten years prior.
Meningococcal Vaccinate if at high risk Vaccinate if at high risk
Polio Vaccinate if at high risk Vaccinate if at high risk

October 7, 2013