From the Guidelines
Before starting high-dose rituximab and plasma exchange (PLEX) treatment for demyelinating neuropathy, a 65-year-old woman should receive several important vaccinations, including the inactivated influenza vaccine, pneumococcal vaccines (PCV20, as per the latest recommendations 1), Tdap (tetanus, diphtheria, pertussis), recombinant zoster vaccine (Shingrix, two doses), hepatitis B vaccine series, and COVID-19 vaccination if not already completed.
Vaccination Strategy
These vaccinations should ideally be administered at least 2-4 weeks before starting immunosuppressive therapy to ensure optimal immune response.
- Inactivated influenza vaccine: should be given on schedule, as recommended by the American College of Rheumatology guideline for vaccinations in patients with rheumatic and musculoskeletal diseases 1.
- Pneumococcal vaccines: PCV20 is recommended for adults aged ≥65 years, with or without underlying medical conditions, as per the latest Advisory Committee on Immunization Practices (ACIP) recommendations 1.
- Tdap (tetanus, diphtheria, pertussis): should be administered according to the general population recommendations.
- Recombinant zoster vaccine (Shingrix, two doses): is recommended for adults aged ≥50 years, including those with autoimmune inflammatory rheumatic diseases, as per the European League Against Rheumatism (EULAR) recommendations 1.
- Hepatitis B vaccine series: should be administered to patients at risk, including those traveling to or resident in endemic countries, and those at increased risk of exposure to HBV.
- COVID-19 vaccination: should be completed before starting immunosuppressive therapy, if not already done.
Rationale
This vaccination strategy is crucial because rituximab depletes B cells, significantly impairing the immune system's ability to respond to vaccines and fight infections after treatment begins. PLEX further compounds this by removing antibodies from the bloodstream. Completing these vaccinations before treatment helps establish protective immunity that can persist during the immunosuppressive period, reducing the risk of potentially serious infections in this vulnerable patient. Live vaccines (like the older shingles vaccine Zostavax) must be avoided as they pose risks to immunocompromised patients.
Additional Considerations
The timing of vaccinations in relation to rituximab treatment is important, as rituximab can impair the immune response to vaccines. The American College of Rheumatology guideline recommends deferring non-live attenuated vaccinations, other than influenza vaccination, until the next rituximab administration is due, and delaying rituximab for 2 weeks after vaccination 1. However, the European League Against Rheumatism (EULAR) recommends vaccinating before starting rituximab, or as long as possible after the last dose (ideally ≥ 6 months) and 4 weeks before the next dose 1.
From the Research
Vaccination Recommendations
Before initiating high-dose rituximab and plasma exchange therapy for demyelinating neuropathy, it is essential to consider the vaccination status of a 65-year-old woman. The following vaccinations are recommended:
- Influenza vaccine: The high-dose inactivated influenza vaccine quadrivalent (HD-IIV4) is recommended for adults aged 65 years and older, as it has been shown to be effective in preventing influenza in this age group 2.
- Pneumococcal vaccine: The pneumococcal conjugate vaccine (PCV) is recommended for adults aged 65 years and older, as it has been shown to be more effective than the pneumococcal polysaccharide vaccine (PPSV) in inducing a T-dependent response and increasing serotype-specific memory B-cell populations 3, 4.
Considerations for Immunocompromised Individuals
It is crucial to note that individuals with demyelinating neuropathy may be immunocompromised, particularly if they are receiving immunosuppressive therapy such as rituximab. In such cases, the response to vaccination may be impaired, and the risk of infections may be increased 4. Therefore, it is essential to consult with a healthcare professional to determine the best vaccination strategy for this individual.
Additional Vaccinations
Other vaccinations, such as the diphtheria, tetanus toxoid, and pertussis vaccine, may also be recommended for adults aged 65 years and older, depending on their individual risk factors and medical history 5. However, the specific vaccinations recommended for this individual will depend on their overall health status and medical history.