What vaccines are needed prior to starting multiple sclerosis (MS) treatment?

Vaccination Recommendations Prior to Starting Multiple Sclerosis Treatment

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

General Vaccination Principles

• All MS patients should follow standard national immunization program recommendations unless specific contraindications exist 2
• Live-attenuated vaccines are contraindicated for patients who will be receiving immunosuppressive therapies 1, 2
• Vaccinations should ideally be administered during periods of disease quiescence whenever possible 3
• Vaccination should be completed before starting immunosuppressive therapy to ensure optimal immune response 1, 2

Essential Vaccines Before Starting MS Treatment

• COVID-19 vaccination: Recommended for all MS patients following national guidelines 1, 3
• Pneumococcal vaccination: Recommended due to increased risk of invasive pneumococcal disease in immunocompromised individuals 1
• Varicella zoster virus (VZV) vaccination: Particularly important for patients who will undergo immunosuppressive therapy due to high risk of herpes zoster infection 1
• Influenza vaccination: Annual vaccination is recommended for all MS patients 2
• Meningococcal vaccines (B and ACWY): Important components of immunization programs for MS patients 4
• Haemophilus influenzae B vaccine: Recommended as part of core immunization for MS patients 4

Timing of Vaccinations Based on MS Treatment

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

• Complete all vaccinations at least 4-6 weeks before starting treatment 3, 1, 5
• If already on therapy, wait at least 6 months after the last dose before vaccination 3

For Immune Reconstitution Therapies (Alemtuzumab, Cladribine):

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

For High-Dose or Long-Term Corticosteroids:

• Delay vaccination until 4-6 weeks after treatment cessation 3, 1

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

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

Special Considerations for Live-Attenuated Vaccines

• MMR (Measles, Mumps, Rubella) and Varicella vaccines must be administered at least 4 weeks before starting immunosuppressive therapy 6
• If time constraints exist before starting treatment, a single-dose attempt of MMR/Varicella may provide protection for approximately two-thirds of patients 6
• Testing for antibody response after a single dose can help determine if additional doses are needed 6

Important Caveats and Pitfalls

• Disease activity should not delay necessary immunosuppressive treatment; if treatment is urgent, immunosuppressive therapy should be prioritized over vaccination 3
• Some DMTs may reduce antibody response to vaccines, but vaccination is still recommended as partial protection is better than none 3, 7
• The median time needed to complete a comprehensive vaccination program before starting MS therapy is approximately 27 days 4
• Vaccination has not been shown to increase risk of MS relapses or disease activity 8, 4
• Patients who have undergone autologous hematopoietic stem cell transplantation should be considered "never vaccinated" and offered complete revaccination starting 3-6 months post-transplant 1