What are the Covid and flu vaccine recommendations for a patient with Myasthenia Gravis (MG)?

COVID-19 and Influenza Vaccination Recommendations for Myasthenia Gravis Patients

Patients with Myasthenia Gravis (MG) should receive both COVID-19 and influenza vaccinations as the benefits significantly outweigh the risks, with inactivated vaccines being the preferred option. 1, 2

COVID-19 Vaccination Recommendations

Safety and Efficacy

• COVID-19 vaccination is strongly recommended for MG patients as they are considered vulnerable due to potential respiratory muscle weakness and immunosuppressive treatments 2
• mRNA COVID-19 vaccines have been shown to be well-tolerated in patients with well-controlled MG, regardless of age, sex, history of myasthenic crisis, or immunosuppressant use 3
• Studies show that COVID-19 infection can have a detrimental effect on MG patients, with significantly increased mortality due to respiratory complications 2

Specific Recommendations

• Inactivated COVID-19 vaccines appear particularly safe for MG patients with MGFA classification I to II (mild disease) 4
• Patients should receive COVID-19 vaccination according to CDC guidelines 1
• Recent data shows that among vaccinated MG patients, approximately 90% do not experience any symptom worsening after vaccination 4
• For the small percentage who do experience worsening (9-10%), symptoms are typically mild and resolve quickly within a few days 4

Timing Considerations

• Vaccination is best administered when MG is stable/well-controlled 3
• If patients are on high-dose or long-term corticosteroids, consider delaying vaccination until 4-6 weeks after treatment if clinically feasible 1

Influenza Vaccination Recommendations

Safety and Efficacy

• Yearly influenza vaccination is recommended for MG patients 1
• The potential benefits of influenza vaccination in preventing serious illness, hospitalization, and death greatly outweigh the possible risks 1
• Inactivated influenza vaccines are preferred over live attenuated influenza vaccines (LAIV) for MG patients 1

Contraindications and Precautions

• Live attenuated influenza vaccines (LAIV) are contraindicated in patients with chronic underlying medical conditions that may predispose to complications after wild-type influenza infection 1
• The only absolute contraindication to influenza vaccination is an anaphylactic or serious allergic reaction to any component of the vaccine 1
• Minor illnesses, with or without fever, are not contraindications to vaccination 1

General Vaccination Guidelines for MG Patients

Key Principles

• Live vaccines are generally contraindicated in MG patients, with the exception of those with complete immune reconstitution (e.g., patients who underwent autologous stem cell transplant >24 months prior) 1
• Close contacts of MG patients should receive seasonal vaccines to create a protective environment 1
• Healthcare providers caring for MG patients should be fully immunized and receive seasonal vaccines 1

Monitoring After Vaccination

• Monitor for potential adverse effects which are typically mild and include injection-site pain, fatigue, myalgia, chills, fever, and headache 3
• Most vaccine reactions are transient and resolve within one week 2
• Worsening of MG symptoms after vaccination is uncommon but possible; patients should be advised to report any new or worsening symptoms 5

Special Considerations

Guillain-Barré Syndrome (GBS) History

• Patients with a history of GBS who are at high risk for severe complications from influenza should still receive vaccination as benefits outweigh risks 1
• As a precaution, people who are not at high risk for severe influenza and who experienced GBS within 6 weeks of a previous influenza vaccination generally should not be vaccinated 1
• For these patients, physicians might consider using influenza antiviral chemoprophylaxis as an alternative 1

Recent Research Findings

• A 2024 study found that COVID-19 vaccines were safe for MG patients in stable condition, with only 2.9% experiencing MG exacerbation after vaccination 5
• Patients with generalized MG may be more susceptible to experiencing MG exacerbation after COVID-19 infection 5
• COVID-19 infection appears to pose a greater risk to MG patients than vaccination, with some studies reporting mortality rates as high as 44% among unvaccinated infected patients 2

Practical Approach

• Assess MG disease stability before vaccination
• Choose inactivated vaccines over live vaccines
• Administer vaccines when disease is stable and immunosuppressive treatment is at maintenance levels
• Monitor for 4 weeks after vaccination for any symptom changes
• Consider pneumococcal vaccination in addition to influenza and COVID-19 vaccines 1