Is the Human Papillomavirus (HPV) vaccine recommended for a 37-year-old male patient with poorly controlled diabetes mellitus (DM) and potential kidney disease (Impaired Renal Function)?

HPV Vaccine for a 37-Year-Old Male with Diabetes and Impaired Renal Function

The HPV vaccine is not routinely recommended for your 37-year-old male patient, as he falls outside the standard age range for vaccination (ages 11-26), though shared clinical decision-making may be considered for ages 27-45 if he has specific risk factors such as being a man who has sex with men (MSM) or being immunocompromised. 1

Historical Context

The quadrivalent HPV vaccine (HPV4) was first recommended by ACIP for males in 2011, initially as a permissive recommendation for ages 9-26 years. 1 The vaccine was later expanded to allow shared clinical decision-making for adults ages 27-45 beginning in 2019. 2

Standard Age-Based Recommendations

Routine Vaccination Ages

• ACIP recommends routine HPV vaccination for males aged 11-12 years (can start as early as age 9), with catch-up vaccination recommended through age 21 for those not previously vaccinated. 1
• Males aged 22-26 years may be vaccinated on a permissive basis, meaning vaccination is optional but not routinely recommended. 1
• The population-level benefits decrease substantially with increasing age at vaccination, especially after age 21 years, because the vaccine is prophylactic and most effective before HPV exposure through sexual contact. 1

Why Age Matters

The vaccine demonstrates highest efficacy in males who have no evidence of previous or current HPV vaccine-type infection, and immunogenicity studies show higher antibody titers when vaccinated at ages 9-15 compared to ages 16-26. 1 By age 37, most sexually active individuals have already been exposed to HPV, significantly reducing vaccine effectiveness. 1

Special Population Considerations for Your Patient

Diabetes Status

The 2022 American Diabetes Association guidelines recommend HPV vaccination for patients with diabetes only if they are under age 26, with shared clinical decision-making for ages 27-45. 1 Your 37-year-old patient exceeds even this extended age range for routine consideration.

Impaired Renal Function

• HPV vaccine is safe and immunogenic in patients with chronic kidney disease, including those with stage IV, V, and dialysis-dependent disease. 3
• The vaccine is not a live vaccine and can be administered to immunocompromised persons, including those with impaired renal function. 1
• For immunocompromised patients with chronic renal failure, ACIP recommends vaccination through age 26 years if not previously vaccinated, but your patient at age 37 still falls outside this recommendation. 4

When to Consider Vaccination at Age 37

High-Risk Groups

You should consider HPV vaccination through shared clinical decision-making if your patient:

• Is a man who has sex with men (MSM), as this population has higher risk for HPV-related anal cancer and genital warts, with cost-effectiveness estimates <$50,000 per quality-adjusted life-year. 1
• Is severely immunocompromised (beyond just impaired renal function), such as transplant recipients or HIV-infected individuals, though even for these groups the recommendation extends only through age 26. 1, 4

Shared Clinical Decision-Making Framework (Ages 27-45)

If considering vaccination for your 37-year-old patient, discuss:

• His likelihood of future HPV exposure based on sexual history and number of lifetime partners 2
• Cost-effectiveness concerns, as vaccination becomes 2-4 times less cost-effective after age 21 compared to adolescent vaccination 1
• Limited benefit if already exposed to vaccine-type HPV strains through prior sexual activity 1

Practical Clinical Algorithm

For your 37-year-old male patient with diabetes and impaired renal function:

1. Do NOT routinely offer HPV vaccination unless he meets high-risk criteria (MSM, severely immunocompromised beyond renal impairment alone). 1

2. If he is MSM or severely immunocompromised, engage in shared clinical decision-making by:

   • Assessing his sexual history and likelihood of future HPV exposure 2
   • Explaining that vaccine benefit decreases substantially with age and prior sexual activity 1
   • Discussing that the vaccine is safe in renal impairment but efficacy may be reduced 3

3. If proceeding with vaccination, use the 3-dose series at 0,2, and 6 months with either quadrivalent or nonavalent vaccine. 4, 3

Common Pitfalls to Avoid

• Do not assume diabetes alone justifies HPV vaccination at age 37—the diabetes guidelines recommend HPV vaccination only for patients <26 years old. 1
• Do not confuse the permissive recommendation for ages 22-26 with routine recommendation—your patient at 37 is well beyond even the permissive age range. 1
• Do not withhold vaccination solely due to renal impairment if the patient otherwise meets criteria, as the vaccine is safe and immunogenic in CKD. 3
• Recognize that cost-effectiveness is poor for vaccination at age 37 compared to adolescent vaccination, with estimates ranging from $141,000-$1,471,000 per quality-adjusted life-year for midadult vaccination. 2