No definitive consensus about a vaccination policy for people with Lupus is currently available, so this review aims to summarise current knowledge on the influence of some current therapies and response to vaccination.
Introduction
Systemic lupus erythematosus (often called Lupus or shortened to SLE) is an autoimmune disease. It typically starts in women between the ages of 15 and 45, but it can also start in childhood. Symptoms can vary, but Lupus often causes tiredness, joint pain, and skin sensitivity to sunlight. Lupus can also affect a person’s inner organs, such as their kidneys, lungs, or brain.
Infections are also common in people with Lupus. In part, this is due to the disease itself, but it can also be caused by medicines for Lupus that dampen down the immune system. Some infections can be prevented with vaccination (also called immunisation), and many countries have routine vaccination programs for common viral or bacterial diseases. But because vaccines work by interacting with the immune system, their effects can differ in people with underlying autoimmune conditions, or in those taking medicines that interact with the immune system, such as the biologics that may be prescribed for people with Lupus – two common ones being rituximab and belimumab.
Understanding how vaccines work in people with Lupus taking biologics is important – both to measure how well they work and protect people from infection, and whether the safety is the same as for people without Lupus and not taking a biologic medicine. It is strongly recommended that people with Lupus receive a pneumococcal and influenza vaccination, but fewer than two-thirds follow this advice.
What did the authors hope to find?
The authors wanted to find out what was already known about the use of vaccines in people taking a biologic medicine for their Lupus, and to identify any issues that might impact either safety, or how well vaccines protect people with Lupus against infection.
Who was studied?
This paper reviewed the latest data about vaccination in people with Lupus. The focus was people with active Lupus being treated with a biologic.
How was the study conducted?
This was a literature review. This means that the authors looked at existing published papers to write a summary of the evidence.
What were the main findings?
The authors believe there are clear benefits to vaccinating people with Lupus. In particular, inactive vaccines appear to be safe. However, it should be kept in mind that using other immunosuppressive drugs alongside biologics might alter the response to vaccination. Clinicians should carefully assess the indications and discuss the risks and benefits with each patient as a part of routine management.
General recommendations for vaccination in people taking a biologic for their Lupus are as follows:
- Pneumococcal vaccine
- If you are on rituximab, you should have had the vaccine before starting treatment. Otherwise, it should be given as long as possible after the last dose (ideally 6 months) and at least 4 weeks before the next dose
- If you are taking belimumab there is no specific statement available; vaccination should be the same as for people without Lupus in the general population
- Influenza (flu) or COVID vaccines
- If you are on rituximab, you should have had the vaccine before starting treatment. Otherwise, it should be given as long as possible after the last dose, and at least 2–4 weeks before the next dose
- If you are taking belimumab there is no specific statement available; vaccination should be the same as for people without Lupus in the general population
- Varicella zoster vaccine
- This vaccine is only for people at high risk, and those over the age of 50
- If you are on rituximab, you should have had the vaccine before starting treatment if you are eligible. Otherwise, it should be given as long as possible after the last dose (ideally 6 months) and at least 4 weeks before the next
- If you are taking belimumab, there are no data are available to support this, so the vaccination decision should be discussed with your healthcare team
- Tetanus vaccine
- If you are taking rituximab, you should be vaccinated before starting treatment
- If you are taking belimumab there is no specific statement available; vaccination should be the same as for people without Lupus in the general population
- Other ‘non-live’ vaccines
- If you are taking rituximab, you should delay vaccination until the next dose is due, and then have your rituximab 2 weeks after the vaccine
Are these findings new?
No. The individual findings are not new, but the authors believe that this is the first time that this body of evidence has been presented and analysed together in the same article.
What are the limitations?
There are limitations, mainly around gaps in our knowledge about individual vaccines and particular biologics.
What do the authors plan on doing with this information?
No new projects are planned, but the authors note that further studies are warranted to monitor the efficacy of vaccines in this specific population.
What does this mean for me?
If you have Lupus, this review might support any discussions you have with your healthcare team about vaccinations. Several vaccines are recommended to help prevent infections – which are the leading cause of poor health and death in people with this disease.
If you have any concerns about your disease or its treatment, you should speak to your doctor.
Date prepared: January 2024
Summary based on research article published on: August 2023
From: Summary from Yıldırım R, et al. Approach to vaccination in systemic lupus erythematosus on biological treatment. Ann Rheum Dis 2023;82(9):1123–1129. doi:10.1136/ard-2023-224071
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