Vaccination and Dermatology Follow-Up Recommendations for Patients on Adalimumab and Azathioprine
Patients on adalimumab and azathioprine should avoid all live vaccines, receive annual inactivated influenza and pneumococcal vaccines, and undergo regular dermatological screening every 3-6 months due to increased malignancy risk, particularly for skin cancers.
Vaccination Recommendations
Contraindicated Vaccines
- Live vaccines are absolutely contraindicated while on adalimumab and azathioprine therapy 1, 2
- MMR (measles, mumps, rubella)
- Varicella/zoster (chickenpox/shingles) live vaccine
- Live oral polio vaccine
- Yellow fever
- Live typhoid
- BCG (tuberculosis)
Recommended Vaccines
- Inactivated influenza vaccine annually 3
- Pneumococcal vaccine (both PCV13 and PPSV23 according to schedule) 3
- Other inactivated vaccines as indicated by age and risk factors:
- Tetanus-diphtheria-pertussis
- Hepatitis B (may have diminished response) 1
- HPV (if age-appropriate)
Special Considerations
- Household members should receive inactive rather than live polio vaccine to prevent orofecal transmission 1
- Patients without prior chickenpox should seek immediate medical attention if exposed to someone with chickenpox or shingles for consideration of zoster immune globulin 1
- Consider administering any needed vaccines at least 2 weeks before initiating immunosuppressive therapy when possible
Dermatology Follow-Up Recommendations
Screening Schedule
- Regular dermatological examinations every 3-6 months due to increased risk of skin malignancies 1
- More frequent monitoring for patients with:
- History of skin cancer
- Extensive sun damage
- Fair skin
- Previous phototherapy
Monitoring Parameters
- Complete skin examination including scalp, nails, oral mucosa, and genital areas
- Special attention to:
- New or changing pigmented lesions
- Non-healing lesions
- Rapidly growing lesions
Patient Education
- Sun protection measures:
- Daily broad-spectrum sunscreen (SPF 30+)
- Protective clothing
- Avoiding peak sun hours (10 AM - 4 PM)
- Wide-brimmed hats
- Self-examination techniques for early detection of skin changes
- Report any new or changing skin lesions promptly
Laboratory Monitoring
For Azathioprine
- Weekly monitoring of FBC and LFTs for the first 4 weeks or until maintenance dose is achieved 1, 2
- Then reduce to a minimum of once every 3 months for the duration of therapy 1
- Return to weekly monitoring following any dose increase 1
- More frequent monitoring for patients with:
- Low TPMT activity
- Hepatic or renal impairment
- Elderly patients
For Adalimumab
- TB screening (tuberculin skin test and chest radiograph) before initiating therapy 1
- Hepatitis B serology before starting treatment 1
- Monitor for signs of infection or reactivation of latent infections
Infection Precautions
- Immediate reporting of fever, signs of infection (cough, chills, wounds with redness/discharge) 1
- Avoid contact with individuals with active infections when possible
- Prompt evaluation of any new respiratory symptoms due to risk of interstitial pneumonias 1
- Heightened vigilance in elderly patients due to increased mortality risk from infections 1
Common Pitfalls and Caveats
Failure to screen for TB and hepatitis B before initiating adalimumab, which can lead to reactivation of latent infections 1
Overlooking drug interactions:
Inadequate monitoring for bone marrow suppression, which can occur even after prolonged stable therapy
Missing early signs of pancreatitis (sudden abdominal pain with/without vomiting) which requires immediate medical attention 1
Failing to counsel patients about malignancy risk with long-term immunosuppressive therapy 1
Administering live vaccines to household contacts without considering the risk to the immunosuppressed patient
By following these comprehensive recommendations, patients on adalimumab and azathioprine can minimize their risk of infections, malignancy, and other complications while maximizing the therapeutic benefits of their immunosuppressive regimen.