What is the recommended vaccination schedule for a patient with Systemic Lupus Erythematosus (SLE) on Methotrexate (MTX) with a history of recurrent pneumonia and infections regarding influenza and pneumococcal vaccines?

Vaccination Recommendations for SLE Patient on Methotrexate with Recurrent Infections

This patient with SLE on methotrexate and recurrent pneumonia should receive both influenza and pneumococcal vaccines urgently, as SLE patients have a 13-fold higher risk of invasive pneumococcal infection compared to the general population, and vaccination is safe and strongly recommended despite immunosuppression. 1

Pneumococcal Vaccination Strategy

Administer PCV13 first, followed by PPSV23 eight weeks later, then a second PPSV23 dose five years after the first PPSV23. 1

Sequential Vaccination Schedule (for vaccine-naïve patients):

• Step 1: Give PCV13 (13-valent conjugate vaccine) immediately 1
• Step 2: Give PPSV23 (23-valent polysaccharide vaccine) 8 weeks after PCV13 1
• Step 3: Give second PPSV23 dose 5 years after the first PPSV23 1
• Step 4: Give third PPSV23 dose at age 65 or later (if at least 5 years have elapsed since last PPSV23) 1

Rationale for Sequential Approach:

The PCV13-prime followed by PPSV23-boost strategy is recommended by CDC and EULAR based on evidence that this sequential approach optimizes immune response in immunocompromised patients, though this is primarily expert opinion rather than direct comparative trials in SLE. 1 While one small trial showed that PCV7 followed by PPSV23 was not superior to PPSV23 alone in SLE patients, current guidelines still recommend the sequential approach based on broader immunocompromised population data. 1

Influenza Vaccination Strategy

Administer annual inactivated influenza vaccine immediately and hold methotrexate for 2 weeks after vaccination if disease activity allows. 1

Key Management Points:

• Use only inactivated (intramuscular) influenza vaccine - live attenuated intranasal vaccine is contraindicated in SLE patients on immunosuppression 1
• Hold methotrexate for 2 weeks post-vaccination to optimize vaccine response, but only if SLE disease activity permits 1
• If uncertain about holding methotrexate, vaccinate anyway and then consult with rheumatology - missing vaccination is worse than suboptimal response 1
• Repeat annually each autumn (September-November optimal, but continue through January or later if needed) 1

Expected Vaccine Response on Methotrexate:

Methotrexate significantly blunts but does not completely eliminate vaccine immunogenicity. 1 Two randomized trials demonstrated that holding methotrexate around influenza vaccination improves immune response. 1 However, protective antibody levels are still reached in the majority of SLE patients despite reduced immunogenicity. 1 The 2-week hold applies only to influenza vaccination, not to pneumococcal or other non-live vaccines where methotrexate should be continued. 1, 2

Critical Safety Considerations

Disease Activity Assessment:

Before holding methotrexate for influenza vaccination, assess whether SLE is stable enough to tolerate a 2-week medication interruption. 1 If disease is active or unstable, vaccinate without holding methotrexate - some protection is better than none, and disease flare risk may outweigh the benefit of improved vaccine response. 1

Glucocorticoid Dosing Impact:

• Prednisone ≤10 mg/day: Strongly recommend all vaccinations 1
• Prednisone >10 but <20 mg/day: Conditionally recommend all vaccinations 1
• Prednisone ≥20 mg/day: Conditionally recommend influenza vaccine; consider deferring other non-live vaccines until steroid taper below 20 mg/day if clinically feasible 1

Immunogenicity Concerns:

While pneumococcal vaccine is safe in SLE, fewer than 40% of SLE patients on immunosuppression achieve adequate immune responses (defined as fourfold increase in ≥70% of serotype-specific IgG responses). 1 However, even suboptimal responses provide some protection, and the 13-fold increased risk of invasive pneumococcal disease in SLE patients justifies vaccination despite reduced efficacy. 1

Common Pitfalls to Avoid

Do not delay vaccination waiting for "optimal" immunosuppression conditions - this patient's recurrent pneumonia history makes immediate vaccination critical, even if response may be suboptimal. 1

Do not use live vaccines - only inactivated influenza vaccine is appropriate; live attenuated intranasal formulations are contraindicated. 1

Do not hold methotrexate for pneumococcal vaccines - the 2-week hold recommendation applies exclusively to influenza vaccination. 1, 2

Do not give PPSV23 before PCV13 - the sequential order matters for optimal immune priming in immunocompromised patients. 1

Do not forget the second PPSV23 dose - immunocompromised patients require a booster at 5 years, unlike immunocompetent adults who may only need one dose until age 65. 1