What is the recommended approach for initiating immune system modulation with Immunostart?

Recommended Approach for Initiating Immune System Modulation with ImmunoStart

For patients requiring immunomodulatory therapy, ImmunoStart should be implemented as a systematic preventive consultation before starting immunosuppressive treatment to reduce infection risks, ensure appropriate vaccination status, and screen for latent infections.

What is ImmunoStart?

ImmunoStart is a preventive consultation designed specifically for patients with immune-mediated inflammatory diseases (IMIDs) who are about to start immunosuppressive or immunomodulatory therapy 1. This structured approach helps prepare patients for immunosuppression by addressing key infection risks before treatment initiation.

Core Components of ImmunoStart Protocol

1. Pre-Treatment Assessment

• Complete vaccination history review
• Blood sampling for serological testing
• Tuberculosis screening (Mantoux test and chest X-ray)
• Comprehensive infectious disease history
• Evaluation of hepatitis B and C status 2

2. Vaccination Planning

• Administer required vaccines before immunosuppression when possible
• Priority timing: Schedule vaccinations to be completed at least 2-4 weeks before starting immunosuppressive therapy 2
• Live vaccines (if needed) must be given ≥4 weeks before immunosuppression 2
• For patients already on therapy, certain immunosuppressants require specific timing considerations:
  • Rituximab: Schedule vaccination ~4 weeks before next dose 2
  • Most other immunomodulators: No delay or adjustment needed 2

3. Latent Infection Management

• Treat latent tuberculosis infection if detected
• For hepatitis B carriers, prophylactic antiviral therapy should begin 2 weeks before immunosuppression 2
• For HBsAg-negative, anti-HBc-positive patients, implement monitoring protocol during immunosuppression 2

Implementation Algorithm

1. Initial Referral: Patient referred by specialist (rheumatology, dermatology, gastroenterology) before starting immunosuppression

2. Pre-ImmunoStart Testing:

   • Complete blood count
   • Hepatitis B and C serology
   • HIV testing
   • Tuberculosis screening (Mantoux/IGRA and chest X-ray)
   • Varicella zoster virus antibody testing
   • Measles, mumps, rubella antibody testing

3. ImmunoStart Consultation:

   • Review test results
   • Develop individualized vaccination plan
   • Prescribe treatment for any latent infections
   • Provide patient education on infection risks

4. Vaccination Implementation:

   • Administer required non-live vaccines
   • If live vaccines needed, delay immunosuppression for ≥4 weeks after vaccination
   • Document all vaccinations administered

5. Latent Infection Treatment:

   • For latent TB: Complete appropriate prophylactic regimen
   • For hepatitis B carriers: Start antiviral prophylaxis 2 weeks before immunosuppression

6. Clearance for Immunosuppression:

   • Final review to ensure all preventive measures completed
   • Provide clearance to treating specialist

Evidence-Based Outcomes

The ImmunoStart approach has demonstrated significant clinical utility. In a study of 437 patients who underwent ImmunoStart consultation 1:

• 96% of patients required at least one vaccine (average 3.3 vaccines per patient)
• 10% needed live attenuated vaccines requiring temporary delay of immunosuppression
• 21% required treatment for latent tuberculosis infection

Common Pitfalls and How to Avoid Them

1. Rushing immunosuppression initiation

   • Allow sufficient time between vaccination and immunosuppression (≥4 weeks for live vaccines)
   • Don't skip TB screening even when urgent therapy is needed

2. Overlooking hepatitis B reactivation risk

   • Screen all patients for HBsAg and anti-HBc before immunosuppression
   • Implement prophylaxis for HBsAg-positive patients

3. Inadequate vaccination planning

   • Consider the specific immunosuppressant when planning vaccination timing
   • Prioritize high-risk vaccines (pneumococcal, influenza) 2

4. Missing latent infections

   • Use both skin testing and chest imaging for TB screening
   • Consider regional endemic infections based on patient history

5. Failure to coordinate care

   • Establish clear communication between ImmunoStart team and treating specialists
   • Document all preventive measures in shared medical records

By implementing this systematic ImmunoStart approach, clinicians can significantly reduce infection-related morbidity and mortality in patients requiring immunosuppressive therapy for immune-mediated inflammatory diseases.