Les 2 articles qui peuvent changer votre pratique sur: Vaccination et biothérapies

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1 Les 2 articles qui peuvent changer votre pratique sur: Vaccination et biothérapies

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3 VZV Epidemiology and Pathogenesis 98% adults Respiratory spread 1,000,000/year and increasing CMI continuously boosted Primary infection with varicella-zoster virus (varicella) Latency Reactivation DRG neuronal cell bodies Zoster sine herpete Zoster (shingles) Immunocompetent patients Immunocompromised patients Myelitis Large-vessel granulomato us arteritis Postherpetic neuralgia Myelitis Small-vessel encephalitis

4 Incidence Rates of VZV in Rheumatic Disease US POPULATION 3.6/ Cases/ OA RA SLE Wegeners

5 Herpes Zoster Vaccine Trials in healthy: Zoster vaccine efficacy 66.5% reduction in the incidence of Post HZ Neuralgia 51.3% reduction in the incidence of HZ Zoster vaccine was safe and efficacious in preventing HZ and PHN in adults 60 years of age and over Most common AE was tenderness and erythema at the injection site (36%) Oxman M et al. Engl J Med 2005;352: Hornberger J and Robertus K. Ann Int Med 2006;145:

6 Herpes Zoster Vaccine in patients with IMIDs: Medicare: Medicare beneficiaries > 60 years with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease Follow-up: 2 years 4% of patients vaccinated Main outcome measures: HZ incidence rate (IR) within 42 days after vaccination and beyond 42 days Zhang et al. JAMA, July 4, 2012:Vol 308 p43-49

7 Herpes Zoster Vaccine in patients with IMIDs: In non vaccinated patients, incidence of HZ increases with steroids use: HR: 1.2 to 2.0 Zhang et al. JAMA, July 4, 2012:Vol 308 p43-49

8 Herpes Zoster Vaccine in patients with IMIDs: In vaccinated patients, The risk of HZ decreases of 40% 633 patients were treated with biologics (551 with anti- TNF) at the time of vaccination Efficacy of vaccination is the same Tolerance was perfect: No varicella or HZ within the first 42 days post-vaccination Zhang et al. JAMA, July 4, 2012:Vol 308 p43-49

9 Zoster Vaccine and Zoster Infection in Patients with Immune-Mediated Diseases Conclusions: Receipt of HZ vaccine was not associated with a short-term increase in HZ incidence in this population, including in those patients exposed to biologics (633 patients) The vaccine was associated with a 40% lower HZ incidence over a median of 2 years of follow-up, including in those patients exposed to biologics (633 patients) Zhang et al. JAMA. 2012; Vol 308 p43-49

10 CDC recommendations The CDC recommends Zostavax for healthy older adults age 60 Newly published guidance from the ACR recommends the vaccine for older RA patients receiving nonbiologic DMARD therapies, or before DMARD or biologic treatments are started The CDC has recommended that individuals receiving lower dose prednisone (< 20 mg/day) or methotrexate (< 0.4 mg/kg) and azathioprine (< 3mg/kg) at doses used for rheumatic diseases may safely receive the vaccine The vaccine is currently considered inadvisable for patients treated with biologic therapies but... MMWR and Annals of IM March in the clinic HZ

11 Is the vaccine useful after a previous episode of zoster? Persons with a previous episode of zoster were excluded form the pivotal trial However: Persons with a reported history of zoster CAN BE vaccinated. Repeated attacks can and do occur soon after a previous episode. Some studies have suggested risk for subsequent attacks may be comparable to those with no history. MMWR June

12 In practice in Europe Zostavax not available When it will be available, what patients need vaccinations? Patients on steroids: Yes if < 20 mg/day Patients before anti-tnf:? Probably possible if necessary in patients on anti- TNF If a life vaccine is safe on anti-tnf, why not doing yellow fever vaccine on anti-tnf? But HZV is a boost of varicella Yellow fever is a primary immunization

13 JID 2012:205 (1 May) d Clutterbuck et al

14 Pneumovax (PCV23) Polysaccharide 23 serotypes Protective against invasive pneumococcal disease Not clearly so for pneumonia Poorly immunogenic Elderly, methotrexate Recommended Immunocompetent adults 65 years All with chronic disease ( 19 years)

15 PCV13 Conjugate vaccine Covers 13 serotypes (12 from PCV23) More immunogenic? Replaced PCV7 in children How to use in adults? Vehement debate

16 Rate of Invasive Pneumococcal Disease in US in persons >5 years of age 40 PCV7 introduced Cases/ population Serotype group PCV7 type non-pcv7 type 19A Year Striking reduction in rate of disease caused by strains contained in 7-valent protein-conjugate pneumococcal vaccine Musher DM. CID 2012 PCV7, 7-valent protein-conjugate pneumococcal vaccine

17 Effect of the 2 vaccines on specific memory B cells JID 2012:205 (1 May) d Clutterbuck et al

18 MMWR 2012;40: JAMA 2013;309:334-6

19 In practice in Europe: Current Advisory Committee on Vaccine Practices (ACIP) Recommendations All adults with chronic medical conditions treated with immunosuppressive drugs Naïve PCV13 (Prevenar) followed by PCV23 (Pneumo- 23) 8 weeks later PCV23 (Pneumo 23) five years later Prior PCV23 (>1 year from last PCV23) PCV13 (Prevenar) PCV23 (Pneumo 23) 5 years after last PCV23 (Pneumo 23) (and no sooner than 8 weeks after PCV13) MMWR 2012;40: JAMA 2013;309:334-6