Pneumococcal Vaccination for a 35-Year-Old Patient with Rheumatoid Arthritis
Pneumococcal vaccination is strongly recommended for this 35-year-old patient with rheumatoid arthritis, especially if they are taking immunosuppressive medications. 1
Rationale for Recommendation
Increased Risk in RA Patients
- Patients with rheumatoid arthritis (RA) taking immunosuppressive medications are at increased risk of pneumococcal infection 1
- The risk of pulmonary infection is particularly high for patients with autoimmune inflammatory rheumatic diseases (AIIRD) 1
- Studies have shown that RA is an additional at-risk condition for pneumococcal disease 1
Evidence Supporting Vaccination
- The 2022 American College of Rheumatology (ACR) guidelines strongly recommend pneumococcal vaccination for patients with rheumatic and musculoskeletal diseases (RMD) under age 65 who are taking immunosuppressive medication 1
- This recommendation is based on low-level evidence but is considered a strong recommendation due to the risk-benefit profile 1
Vaccination Strategy
Current Recommendations
The CDC currently recommends one of the following strategies for adults under 65 years taking immunosuppressive medications:
- PCV15 followed by PPSV23 one year later
- A single-dose PCV20 vaccine 1
Considerations for Vaccine Selection
- The single-dose PCV20 vaccine is likely to supplant the two-dose strategy in adults 1
- The vaccination strategy should follow the most current CDC guidelines, as this area is rapidly changing 1
Vaccine Response in RA Patients
Immunogenicity
- Multiple studies have demonstrated that patients with RA can mount an appropriate immune response to pneumococcal vaccines, even while on immunosuppressive therapy 2, 3
- In one study, 73.9% of RA patients on abatacept achieved an immunologic response to PPSV23 2
- Another study showed that 80% of RA patients achieved protective levels of antibodies after pneumococcal vaccination 4
Impact of Medications
- Methotrexate may reduce response to pneumococcal vaccination 4
- Patients on TNF inhibitors plus methotrexate may have lower antibody quantities but maintain adequate functional antibody responses 3
Important Considerations
Timing of Vaccination
- Ideally, pneumococcal vaccination should be administered before initiating methotrexate therapy when possible 4
- No need to hold most immunosuppressive medications around the time of vaccination 1
Efficacy Concerns
- A randomized controlled trial did not demonstrate increased efficacy of PPSV23 over placebo in preventing pneumonia in RA patients 5
- However, a retrospective study showed a 9.7-fold increased risk of developing pneumonia in non-vaccinated RA patients compared to vaccinated patients 1
Compliance Issues
- Compliance with pneumococcal vaccination in RA patients has been suboptimal, with only 43.9% of patients being vaccine compliant in one large study 6
- Providers should identify and address barriers to pneumococcal vaccination in RA patients 6
Despite some mixed evidence regarding efficacy, the potential benefits of pneumococcal vaccination in reducing the risk of serious pneumococcal disease in this immunocompromised population strongly outweigh any risks, making vaccination the recommended approach for this 35-year-old patient with RA.