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A 24-year-old Patient with Crohn's Disease Starting Immunosuppressive Therapy: Vaccination Issues to Consider
Sharmeel K; Wasan; Paul R. Skolnik; Francis A. Farraye
Clin Gastroenterol Hepatol. 2010;8(12):1016-1016. © 2010 AGA Institute
Clinical Scenario
A 24-year-old preschool teacher with a 3-year history of Crohn's disease (CD) presents to your office for a second opinion regarding the management of 4-week history of worsening abdominal pain and diarrhea. She has lost 8 pounds during this time. On physical examination, she has tenderness in the right lower quadrant. Colonoscopy is performed and reveals progression of her disease, with evidence of severe terminal ileitis and moderate extensive colitis. She notes that she has been compliant with her mesalamine regimen. Her father also has CD, maintained on 6-mercaptopurine (6-MP), and recently developed a severe episode of herpes zoster. After a long discussion, the decision is made to initiate therapy with an anti–tumor necrosis factor (anti-TNF) agent. She is concerned about infections and wants to know what she can do to minimize her risk.
The Problem
Current medical management of CD includes the use of various immunosuppressive therapies, including corticosteroids, immunomodulators (such as 6-MP, azathioprine, and methotrexate), and biologics (infliximab, adalimumab, certolizumab, and natalizumab). Although effective in treating CD, these medications also put patients at risk for various infections. As described in the case above, the patient's father developed herpes zoster while on an immunomodulator. Although the overall incidence of vaccine-preventable illnesses among inflammatory bowel disease (IBD) patients is unknown, case reports of patients developing fatal varicella or fulminant hepatitis while on immunosuppressive therapy have been described in the literature. Despite these severe events, many IBD patients are still not being adequately vaccinated. In a survey study of 108 gastroenterologists, the majority believed that the primary care physician was responsible both for determining which vaccinations to give the IBD patient (65%) and for administering the vaccine (83%). In this same study, gastroenterologist knowledge of the appropriate vaccinations for the IBD patient was also noted to be poor. In addition, there are patient factors that are barriers to vaccinations. In a survey of 169 patients, only 28% had regularly received the influenza vaccine, and only 9% had received the pneumococcal vaccine. Many patients are afraid of the side effects of the vaccine, think that the vaccine will make their IBD worse, or are skeptical as to whether vaccinations are effective at all. Educational programs on vaccinations directed to gastroenterologists who prescribe immunosuppressive agents and to patients receiving these medications are therefore crucial to improving vaccination rates and compliance. Recommendations for vaccinations should then be provided by the gastroenterologist to the patient and the primary care physician for appropriate administration.
Management Strategies and Supporting Evidence
Live Vaccines
The basic management strategy involves avoiding the live, attenuated vaccines in the immunosuppressed patient because of concerns about vaccine-related infections. The measlesmumps-rubella (MMR), varicella, and herpes zoster vaccines are the 3 most commonly administered live, attenuated vaccines. Because of the risk for prolonged viremia with the MMR vaccine, any patient who is anticipating immunosuppressive therapy within the ensuing 6 weeks should avoid MMR vaccination. Similarly, waiting at least 4–12 weeks between administering the varicella or herpes zoster vaccines and initiation of immunosuppressive therapy has also been recommended. In patients without a history of varicella exposure (or vaccination), or who do not have serologic evidence of immunity, who work in environments with a high risk of exposure to primary varicella infection, delaying immunomodulators and anti-TNF agents until a sufficient period has elapsed after vaccination with the live, attenuated vaccine should be considered after weighing the risks and benefits for each particular patient. Because the incidence of herpes zoster is higher in IBD patients than in patients without IBD, the immunosuppressed state must be carefully defined. In regard to the herpes zoster vaccine, the Advisory Committee on Immunization Practices states that patients on short-term corticosteroid therapy (<14 days), low doses of methotrexate (<0.4 mg/kg/week), or low doses of 6-MP (<1.5 mg/kg/day)/azathioprine (<3.0 mg/kg/day) are not sufficiently immunosuppressed to increase the risks associated with a live, attenuated vaccine, and as a result, the herpes zoster vaccine might be administered.
The anthrax, intranasal influenza, oral polio, smallpox, Bacillus Calmette–Guérin, oral typhoid, and yellow fever vaccines are the other live, attenuated vaccines that should be avoided in the immunocompromised IBD patient who might be traveling to endemic areas. Consultation with an infectious diseases travel medicine expert is indicated in these situations to counsel patients as to the advisability of travel or alternative methods of prevention (eg, the inactivated typhoid or influenza vaccines).
Inactivated Vaccines
The inactivated vaccines are considered to be safe for administration, regardless of the state of immunosuppression. Patients should therefore follow the recommended vaccine schedule for adults and receive the tetanus, diphtheria, pertussis, human papillomavirus (HPV), influenza, pneumococcal, hepatitis A, hepatitis B, and meningococcal vaccines as indicated.
Sharmeel K; Wasan; Paul R. Skolnik; Francis A. Farraye
Clin Gastroenterol Hepatol. 2010;8(12):1016-1016. © 2010 AGA Institute
Clinical Scenario
A 24-year-old preschool teacher with a 3-year history of Crohn's disease (CD) presents to your office for a second opinion regarding the management of 4-week history of worsening abdominal pain and diarrhea. She has lost 8 pounds during this time. On physical examination, she has tenderness in the right lower quadrant. Colonoscopy is performed and reveals progression of her disease, with evidence of severe terminal ileitis and moderate extensive colitis. She notes that she has been compliant with her mesalamine regimen. Her father also has CD, maintained on 6-mercaptopurine (6-MP), and recently developed a severe episode of herpes zoster. After a long discussion, the decision is made to initiate therapy with an anti–tumor necrosis factor (anti-TNF) agent. She is concerned about infections and wants to know what she can do to minimize her risk.
The Problem
Current medical management of CD includes the use of various immunosuppressive therapies, including corticosteroids, immunomodulators (such as 6-MP, azathioprine, and methotrexate), and biologics (infliximab, adalimumab, certolizumab, and natalizumab). Although effective in treating CD, these medications also put patients at risk for various infections. As described in the case above, the patient's father developed herpes zoster while on an immunomodulator. Although the overall incidence of vaccine-preventable illnesses among inflammatory bowel disease (IBD) patients is unknown, case reports of patients developing fatal varicella or fulminant hepatitis while on immunosuppressive therapy have been described in the literature. Despite these severe events, many IBD patients are still not being adequately vaccinated. In a survey study of 108 gastroenterologists, the majority believed that the primary care physician was responsible both for determining which vaccinations to give the IBD patient (65%) and for administering the vaccine (83%). In this same study, gastroenterologist knowledge of the appropriate vaccinations for the IBD patient was also noted to be poor. In addition, there are patient factors that are barriers to vaccinations. In a survey of 169 patients, only 28% had regularly received the influenza vaccine, and only 9% had received the pneumococcal vaccine. Many patients are afraid of the side effects of the vaccine, think that the vaccine will make their IBD worse, or are skeptical as to whether vaccinations are effective at all. Educational programs on vaccinations directed to gastroenterologists who prescribe immunosuppressive agents and to patients receiving these medications are therefore crucial to improving vaccination rates and compliance. Recommendations for vaccinations should then be provided by the gastroenterologist to the patient and the primary care physician for appropriate administration.
Management Strategies and Supporting Evidence
Live Vaccines
The basic management strategy involves avoiding the live, attenuated vaccines in the immunosuppressed patient because of concerns about vaccine-related infections. The measlesmumps-rubella (MMR), varicella, and herpes zoster vaccines are the 3 most commonly administered live, attenuated vaccines. Because of the risk for prolonged viremia with the MMR vaccine, any patient who is anticipating immunosuppressive therapy within the ensuing 6 weeks should avoid MMR vaccination. Similarly, waiting at least 4–12 weeks between administering the varicella or herpes zoster vaccines and initiation of immunosuppressive therapy has also been recommended. In patients without a history of varicella exposure (or vaccination), or who do not have serologic evidence of immunity, who work in environments with a high risk of exposure to primary varicella infection, delaying immunomodulators and anti-TNF agents until a sufficient period has elapsed after vaccination with the live, attenuated vaccine should be considered after weighing the risks and benefits for each particular patient. Because the incidence of herpes zoster is higher in IBD patients than in patients without IBD, the immunosuppressed state must be carefully defined. In regard to the herpes zoster vaccine, the Advisory Committee on Immunization Practices states that patients on short-term corticosteroid therapy (<14 days), low doses of methotrexate (<0.4 mg/kg/week), or low doses of 6-MP (<1.5 mg/kg/day)/azathioprine (<3.0 mg/kg/day) are not sufficiently immunosuppressed to increase the risks associated with a live, attenuated vaccine, and as a result, the herpes zoster vaccine might be administered.
The anthrax, intranasal influenza, oral polio, smallpox, Bacillus Calmette–Guérin, oral typhoid, and yellow fever vaccines are the other live, attenuated vaccines that should be avoided in the immunocompromised IBD patient who might be traveling to endemic areas. Consultation with an infectious diseases travel medicine expert is indicated in these situations to counsel patients as to the advisability of travel or alternative methods of prevention (eg, the inactivated typhoid or influenza vaccines).
Inactivated Vaccines
The inactivated vaccines are considered to be safe for administration, regardless of the state of immunosuppression. Patients should therefore follow the recommended vaccine schedule for adults and receive the tetanus, diphtheria, pertussis, human papillomavirus (HPV), influenza, pneumococcal, hepatitis A, hepatitis B, and meningococcal vaccines as indicated.