What vaccinations are recommended prior to starting treatment for multiple sclerosis (MS)?

Recommended Vaccinations Prior to Multiple Sclerosis Treatment

Patients with multiple sclerosis should receive all recommended vaccinations at least 4-6 weeks before starting immunosuppressive therapy, with specific timing requirements based on the planned treatment. 1

General Vaccination Principles for MS Patients

• All MS patients should follow local vaccine standards and routine adult vaccination schedules unless there are specific contraindications 2
• Vaccination should ideally be administered during quiescent disease whenever possible, but necessary treatment should never be postponed due to vaccination 3
• Vaccines should be administered 2-4 weeks prior to commencement of immunosuppression, especially B-cell depleting therapies 3, 1

Essential Vaccines Recommended Before MS Treatment

• Pneumococcal vaccination is recommended due to increased risk of invasive pneumococcal disease in immunocompromised individuals 1
• Varicella zoster virus (VZV) vaccination is recommended, particularly for patients who will undergo immunosuppressive therapy 1
• Annual influenza vaccination is recommended for all MS patients 2
• COVID-19 vaccination is recommended for all MS patients following national guidelines 3, 1
• Meningococcal (B and ACWY), pneumococcal conjugated, and Haemophilus influenzae B vaccines are considered core vaccines for MS patients starting immunosuppressive therapy 4

Timing of Vaccinations Based on MS Treatment Type

For B-cell Depleting Therapies (Rituximab, Ocrelizumab):

• Complete all vaccinations at least 4-6 weeks before starting treatment 3, 1
• If already on therapy, vaccination should be delayed until at least 6 months after the last dose 3

For Immune Reconstitution Therapies (Alemtuzumab, Cladribine):

• Complete vaccinations at least 4-6 weeks before starting treatment 3, 1
• If already on therapy, delay vaccination until at least 6 months after the last course of treatment 3, 1

For High-Dose Corticosteroids:

• Vaccination should be delayed until 4-6 weeks after cessation of treatment 3

For Other DMTs (β-interferons, glatiramer acetate, teriflunomide, dimethyl fumarate, natalizumab, fingolimod, ozanimod, siponimod):

• Patients can be vaccinated at any time during treatment, though vaccine response may be attenuated 3

Important Considerations and Contraindications

• Live-attenuated vaccines are contraindicated for patients already on immunosuppressive therapies 1, 5
• Disease-modifying therapies (DMTs) may reduce antibody response to vaccines, but vaccination is still recommended 3, 6
• For patients with active underlying disease, immunosuppressive therapy should be prioritized over vaccination 3
• Vaccination should be delayed in patients experiencing an MS relapse 2
• For vaccines with a correlate of protection, monitor serological response 1-2 months after the last dose 5

Practical Implementation

• A complete vaccination program before starting MS therapy can typically be completed in approximately 27 days 4
• Screening for latent infections should be performed before initiating immunosuppressive therapy 2
• Systemic infections can worsen MS, thus vaccination will lower the risk of relapses by reducing infection risk 6

Special Considerations for Patients After AHSCT

• Consider MS patients who have undergone autologous hematopoietic stem cell transplantation as "never vaccinated" and offer complete revaccination 1
• Start pneumococcal vaccination with three doses at 1-month intervals beginning 3-6 months post-transplant 1