Vaccination Guidelines for Patients with Immune-Mediated Disorders Receiving Immunosuppressive Drugs (2019)

Canadian Physician Multidisciplinary Committee

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 04, 2019

A Canadian multidisciplinary committee has issued vaccination guidelines for patients with immune-mediated diseases who are receiving or will be receiving immunosuppressive treatment.[1]

Initial Assessment and Timing of Vaccination

Patients with a newly diagnosed immune-mediated disease should undergo an assessment of immunization status. Age- and condition-appropriate vaccines should be administered before immunosuppressive treatment is initiated.

Inactivated Vaccines

Immunization should be administered at least 2 weeks before immunosuppressive therapy is initiated, when possible, in treatment-naïve patients with immune-mediated conditions so that immunogenicity of inactivated vaccines can be optimized.

Immunosuppressive treatment that is currently being administered to patients with immune-mediated diseases should not be interrupted for the administration of inactivated vaccines.

In patients with an immune-mediated disease undergoing rituximab treatment in whom optimal vaccine immunogenicity is required, immunization should be deferred to 5 months or later after the last dose and, at minimum, 4 weeks prior to administration of the subsequent rituximab dose.

Herpes Zoster Vaccine

The live attenuated herpes zoster vaccine should be administered at least 2-4 weeks before immunosuppressive therapy is initiated in treatment-naïve patients with an immune-mediated condition so that immunogenicity can be optimized.

The subunit vaccine is preferred over the live attenuated vaccine in patients with immune-mediated diseases currently receiving immunosuppressive agents, although the latter is safe in these patients. If the live vaccine is being considered in patients receiving a combination of immunosuppressive drugs, assessment should occur on a case-by-case basis.

Note that the Centers for Disease Control and Prevention (CDC) recommends the use of the herpes zoster subunit vaccine over the live attenuated version.

Other Live Attenuated Vaccines

The duration of viremia following immunization should be considered when the optimal time to initiate immunosuppressive therapy is determined in treatment-naïve patients with an immune-mediated disease who receive live attenuated vaccines.

The duration of viremia following immunization should be considered when the optimal time to resume immunosuppressive therapy is determined in patients with an immune-mediated disease whose immunosuppressive treatment is interrupted for vaccination.

Live attenuated vaccines should be administered when benefits outweigh the perceived risks in patients with an immune-mediated disease receiving immunosuppressive drugs.

When patient safety is paramount and the clinical situation permits, immunosuppressive treatment should be interrupted prior to immunization with live vaccines, with the interruption duration based on drug pharmacokinetics.

Vaccination of Infants With Early Exposure to Immunosuppressive Drugs

Infants with in utero exposure to immunosuppressive agents during the third trimester should receive inactivated vaccines; measles, mumps, rubella (MMR) vaccine; and varicella vaccine according to the local immunization schedule.

Infants breastfed by mothers receiving immunosuppressive drugs should receive inactivated and live attenuated vaccines without delay according to the local immunization schedule.

For more Clinical Practice Guidelines, please go to Guidelines.

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