What vaccinations are recommended for a patient with psoriasis before starting secukinumab (interleukin-17A inhibitor) therapy?

Vaccination Recommendations Before Starting Secukinumab for Psoriasis

Patients should complete all indicated killed (inactivated) vaccines before starting secukinumab, and live attenuated vaccines must be administered at least 2-4 weeks before initiating therapy, though starting the biologic without delaying for killed vaccines is acceptable if disease severity warrants immediate treatment. 1, 2

Pre-Treatment Vaccination Strategy

Tuberculosis Screening (Mandatory)

• Screen all patients for active tuberculosis before initiating secukinumab 2
• Consider anti-tuberculosis therapy before starting secukinumab in patients with latent TB 1, 2

Live Attenuated Vaccines (Must Be Given Before Therapy)

• Live vaccines are absolutely contraindicated once secukinumab is started due to risk of severe or fatal infections from vaccine strain replication 1
• Live vaccines available in the U.K. include: BCG, measles, mumps, rubella, yellow fever, oral polio, and oral typhoid 1
• Delay starting secukinumab to administer live attenuated vaccines over starting the biologic and giving live vaccines concurrently 1
• The only exception: patients with very active severe joint or skin disease who prefer no delay in biologic initiation may consider starting therapy, though this carries significant risk 1
• After administering live vaccines, wait at least 2 weeks before starting secukinumab (per ustekinumab guidance as proxy, since secukinumab-specific data are unavailable) 1

Killed (Inactivated) Vaccines (Preferred Before Therapy But Not Mandatory to Delay)

• Start the biologic and administer killed vaccines over delaying the start of biologic to administer killed vaccines 1
• Inactivated vaccines are safe to give to patients already receiving secukinumab 1
• However, vaccine efficacy may be reduced once on therapy, so ideally complete before starting if time permits 1

Specific Vaccine Recommendations

Pneumococcal Vaccine

• Strongly recommended before starting any biologic therapy 1
• IL-17 inhibitors (including secukinumab) do not interfere with immune response to pneumococcal vaccination, unlike methotrexate which significantly impairs humoral responses 1

Influenza Vaccine

• Annual influenza vaccination recommended 1
• IL-17 inhibitors and ustekinumab do not interfere with immune response to influenza vaccination 1
• Can be administered after starting secukinumab if necessary 1

Hepatitis B Vaccine

• Screen for hepatitis B status; untreated hepatitis B infection is a relative contraindication for secukinumab 2
• If seronegative (61% of psoriasis patients in one study), complete hepatitis B vaccination series before starting therapy 3

COVID-19 Vaccination

• Patients with psoriatic disease should receive COVID-19 vaccines (mRNA-based when available) as soon as eligible 1
• IL-17 inhibitors do not significantly impair vaccine response based on data from other vaccines 1

Practical Implementation Algorithm

1. At initial consultation (before prescribing secukinumab):

   • Screen for active tuberculosis and treat latent TB if present 1, 2
   • Review immunization records (only one-third of patients bring records to appointments) 3
   • Check hepatitis B serology 2, 3
   • Assess for active infections or sepsis 2

2. Determine vaccination needs:

   • Identify any needed live vaccines (measles, mumps, rubella, varicella, yellow fever if travel planned) 1, 3
   • Identify needed killed vaccines (pneumococcal, influenza, hepatitis B, DTP/pertussis) 3

3. If live vaccines are needed:

   • Administer live vaccines first 1
   • Wait minimum 2 weeks after live vaccine before starting secukinumab 1
   • Only proceed without this delay if disease severity is very high and patient accepts risk 1

4. If only killed vaccines are needed:

   • Ideally administer before starting secukinumab for optimal immune response 1
   • However, can start secukinumab without delay and give killed vaccines concurrently or shortly after if disease severity warrants immediate treatment 1

5. Once secukinumab is started:

   • Never administer live vaccines during therapy 1
   • Killed vaccines can be given safely but may have reduced efficacy 1

Common Pitfalls to Avoid

• Do not assume patients are up to date with vaccinations - only 1% of psoriasis patients starting immunosuppressants are fully up to date with all recommended vaccines 3
• Do not give live vaccines after starting secukinumab - this can cause severe or fatal infections 1
• Do not forget to ask about travel plans - patients traveling to yellow fever-endemic areas need vaccination before starting therapy 3
• Do not rely on patient recall alone - 78% stated they had chickenpox but serologic testing should confirm immunity 3
• The most common reason for incomplete vaccination is failure of the physician to notify or propose vaccination - proactively address this at every visit 3