What pneumonia vaccine is recommended for patients with Crohn's disease, especially those on immunosuppressive therapy?

Pneumococcal Vaccination Recommendations for Patients with Crohn's Disease

For patients with Crohn's disease on immunosuppressive therapy, both pneumococcal conjugate vaccine (PCV13/15/20) and pneumococcal polysaccharide vaccine (PPSV23) are recommended, with PCV given first followed by PPSV23 at least 8 weeks later. 1

Vaccination Recommendations Based on Patient Status

For Adult Patients with Crohn's Disease on Immunosuppressive Therapy:

• Both PCV (13/15/20) and PPSV23 vaccines are recommended 1
• PCV should be administered first, followed by PPSV23 at least 8 weeks later 1
• Vaccination should ideally be given before starting immunosuppressive therapy whenever possible 1
• Patients on combination therapy (anti-TNF plus immunomodulators) have particularly impaired immune responses and should be prioritized for vaccination 2, 3

For Adult Patients with Crohn's Disease Not on Immunosuppressive Therapy:

• Pneumococcal vaccination is strongly recommended if they have other risk factors for pneumococcal disease 1
• For those without additional risk factors, the evidence is less clear, but vaccination should be considered given the potential for future immunosuppressive therapy 1

For Pediatric Patients with Crohn's Disease:

• Age-appropriate pneumococcal vaccines are strongly recommended regardless of immunosuppression status 1
• For children with IBD on immunosuppressive therapy, follow the same PCV first, then PPSV23 approach 1

Rationale and Evidence

Increased Risk in Crohn's Disease Patients

• Patients with Crohn's disease have approximately 1.5-2 fold higher risk of invasive pneumococcal disease compared to those without IBD 1
• The risk increases further with immunosuppressive therapy, particularly with combination therapy 3
• Rates of all-cause pneumonia and invasive pneumococcal disease in immunocompromised adults are 5.3 and 10.5 times higher than in healthy adults 1

Vaccine Effectiveness

• PCV13 has shown higher antibody responses for some serotypes (particularly 9V and 23F) compared to PPSV23 in patients with Crohn's disease 2
• A recent study showed that PCV13 alone or in combination with PPSV23 predicted a 5-fold decreased risk of severe pneumococcal disease compared to no vaccination in IBD patients 3
• Immunosuppressive therapy, especially anti-TNF agents alone or in combination with immunomodulators, significantly impairs antibody response to both vaccines 4, 2

Timing Considerations

• Vaccination should ideally be administered before initiating immunosuppressive therapy 1
• Patients already on immunosuppressive therapy should still receive vaccination, as some protective effect is still achieved 5
• Sustained high-dose corticosteroids (≥10 mg/day of prednisone) are associated with poor vaccine response and more infections 5

Practical Implementation

• Assess vaccination status at diagnosis and before starting immunosuppressive therapy 1
• For patients on anti-TNF therapy, the response rate to pneumococcal vaccination is significantly reduced (57.6% vs 88.6% in those on mesalamine) 4
• Pneumococcal vaccines are generally safe and well-tolerated in patients with IBD 1, 4
• The British Society of Gastroenterology recommends pneumococcal vaccination with a booster after 5 years for IBD patients on immunomodulators or biologics 1

Newer Vaccine Options

• Since 2021, newer pneumococcal vaccines (PCV15, PCV20, and PCV21) with broader serotype coverage are available 1
• Single-dose PCV20 or PCV21 is preferred to the two-dose PCV15 followed by PPSV23 regimen 1

Remember that vaccination is particularly important for patients who will be starting immunosuppressive therapy, and should be administered as early as possible in the disease course to maximize immune response.