AAN Updates Its Guideline on Vaccines in Multiple Sclerosis: What Providers Need to Know

People with multiple sclerosis (MS) should receive recommended vaccines, including yearly flu shots, but the timing of some vaccines must be carefully considered depending on the disease-modifying therapy (DMT) patients are taking. So advises Alex Rae-Grant, MD, Director of Education for Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research and co-author of a new practice guideline update on the topic from the American Academy of Neurology (AAN).

“We know that people with MS who don’t receive vaccines are at higher risk of acquiring preventable infections, and these infections may provoke relapses and progression of disability,” says Dr. Rae-Grant, who also serves as chair of the AAN’s guideline subcommittee. “We also know that people with MS who are receiving immunosuppressive therapy may have an additional increase in risk, so immunizations are critically important to our patients’ overall health.”

Addressing vaccine resistance

Despite resounding evidence to refute vaccine skepticism in the broader culture, some people with MS may be wary of vaccinations due to specific concerns that immunization may lead to relapse. Dr. Rae-Grant notes, however, that a systematic review conducted by the AAN guideline subcommittee found no relationship between immunizations and causation or worsening of MS.

“This is important confirmation of what we found in 2002 when the AAN last reviewed this topic, and it’s helpful information to share with patients who may be skeptical of vaccines,” he says. “I find that some of my patients with MS are concerned about getting flu vaccines every year. I tell those patients, ‘If you get influenza, you will get very, very sick, and there is less risk from vaccinating than from actually getting the flu.’ That message is usually persuasive.”

A need to account for all the new DMTs

Since the 2002 release of the prior guideline, a revolution has occurred in new therapeutics for MS. “There are about 20 DMTs on the market now, and the whole treatment landscape has changed dramatically,” says Dr. Rae-Grant. “Most neurologists need to know how to advise patients with MS on immunizations.”

A critical update in the new document is the evaluation of effectiveness of immunizations in patients receiving DMTs. Moreover, the newer immunosuppressive/immunomodulating (ISIM) medications now used for MS — such as alemtuzumab, dimethyl fumarate, fingolimod, natalizumab, ocrelizumab, rituximab and teriflunomide — were not approved for MS in 2002, so the interaction between vaccines and these drugs was not evaluated at that time.

Key overarching recommendations

Dr. Rae-Grant notes that although vaccine recommendations should be made on a case-by-case basis, the AAN subcommittee was able to arrive at the following general guidance:

• To avoid the potential for complications, people with MS still should not receive vaccinations during relapses. This is especially true for those receiving high doses of steroids, which suppress immune response and thus may also reduce the benefit of immunization.
• Candidates for ISIM medications should be vaccinated four to six weeks before initiating treatment and according to their medication’s specific prescribing information. “We know that vaccines should be given before patients begin on major immune-modifying drugs,” explains Dr. Rae-Grant. “This wasn’t a concern when we were just using injectable DMTs, but neurologists today need to carefully consult the package inserts for all DMTs they are prescribing to be aware of their vaccine recommendations.”
• Live-attenuated vaccines are not recommended immediately preceding, during or after treatment with ISIM medications due to the potential to trigger an MS relapse or progression of disability.
• Patients should be screened for infections such as hepatitis, tuberculosis and varicella according to prescribing information before starting most ISIM therapies. If they don’t have antibodies to these infections, they should be vaccinated at least four to six weeks before treatment. For example, Dr. Rae-Grant notes, patients who are to receive fingolimod, which has been associated with a number of disseminated varicella infections, should be assessed to determine if they have antibodies to varicella infection and vaccinated as needed.
• Live-attenuated vaccines may be considered in high-risk individuals on ISIM therapies when killed vaccines are unavailable. “Neurologists need to be aware of local disease emergence, such as yellow fever in their area, and vaccinate their patients accordingly,” Dr. Rae-Grant advises.