Can a patient taking abatacept (Orencia) receive the pneumonia vaccine?

Can Patients Taking Abatacept Receive the Pneumonia Vaccine?

Yes, patients taking abatacept (Orencia) can and should receive pneumococcal vaccination, though the vaccine may be less effective than in patients not on immunosuppressive therapy. 1, 2

Guideline Recommendations

Pneumococcal vaccination is strongly recommended for the majority of patients with autoimmune inflammatory rheumatic diseases (AIIRD), including those on abatacept. 1 The 2019 EULAR guidelines specifically state that pneumococcal vaccination should be strongly considered for patients with AIIRD, as these patients face particularly high risks of pulmonary infections. 1

The FDA-approved drug label for abatacept explicitly states: "You can receive non-live vaccines, such as pneumococcal and inactivated influenza (flu) vaccines" while on ORENCIA treatment. 2 This confirms that pneumococcal vaccines are safe to administer during abatacept therapy.

Vaccine Type Selection

For patients on abatacept, use inactivated pneumococcal vaccines (PCV13, PCV15, PCV20, or PPSV23)—never live vaccines. 1, 2

Current ACIP recommendations for adults ≥65 years prioritize:

• Single dose of PCV20 (preferred option), OR 3
• PCV15 followed by PPSV23 at least 1 year later 3

For immunocompromised patients on immunosuppressive therapy like abatacept, the interval between PCV and PPSV23 should be shortened to at least 8 weeks rather than 1 year. 3

Timing Considerations

Ideally, vaccinate before starting abatacept therapy when possible, as the immune response will be more robust. 1 However, if the patient is already on abatacept, do not delay vaccination—the benefits still outweigh the risks. 1

The FDA label advises: "Prior to initiating ORENCIA in pediatric and adult patients, update vaccinations in accordance with current vaccination guidelines." 2 Live vaccines should not be given concurrently with abatacept or within 3 months after discontinuation. 2

Expected Immune Response

Abatacept modestly reduces pneumococcal vaccine immunogenicity, but most patients still achieve protective antibody levels. 1, 4

Research evidence shows:

• In one study, 73.9% of abatacept-treated patients achieved an immunologic response to PPSV23, with 83.9% demonstrating protective antibody levels post-vaccination 4
• Abatacept appears to have less impact on vaccine response compared to rituximab, which profoundly impairs responses 1, 5
• The impairment is more pronounced when abatacept is combined with methotrexate 1, 6
• Despite lower antibody concentrations, opsonophagocytic activity (functional antibody response) may be preserved 6

A meta-analysis found that abatacept was associated with pooled odds ratios for non-seroconversion ranging from 4.91 to 13.06 depending on serotype, though this effect was less severe than with rituximab. 1

Safety Profile

Pneumococcal vaccination is safe in patients on abatacept, with no increased risk of disease flares or serious adverse events. 4, 7

Clinical trials demonstrated that vaccines were well tolerated in patients receiving subcutaneous abatacept with background DMARDs. 4 No severe adverse effects were observed in vaccination studies of abatacept-treated patients. 6

Important Caveats

• Concomitant methotrexate further reduces vaccine response: Patients on both abatacept and methotrexate show lower antibody responses than those on abatacept monotherapy 1, 6
• Low-dose corticosteroids (<20 mg/day prednisone) do not significantly impact response, but high-dose steroids may 1
• Monitor for infections closely: The FDA label warns that abatacept increases infection risk, and patients should be monitored for new infections during treatment 2
• Consider booster strategies: A second vaccine dose may improve immunogenicity in immunosuppressed patients 1

Practical Algorithm

1. Check vaccination history before initiating abatacept therapy 2
2. If unvaccinated and not yet on abatacept: Give PCV20 (or PCV15 + PPSV23) before starting therapy 1, 3
3. If already on abatacept: Proceed with vaccination using PCV20 or the PCV15/PPSV23 sequence 3, 2
4. If immunocompromised: Use 8-week interval between PCV15 and PPSV23 (not 1 year) 3
5. Document vaccination and consider checking post-vaccination titers in high-risk patients 1