1/10/13 Two recent studies show that flu vaccines are effective and protective in most people with RA and lupus, while causing little to no disease flare. The autoimmune diseases and some medications taken to suppress inflammation and the immune system may decrease the amount of protection provided by from the vaccine, the protection that is gained creates an important margin of safety for avoiding the flu and the potentially serious complications that can come from it.

Rheumatoid Arthritis

A Brazilian study presented at the annual meeting of the European League Against Rheumatism in May 2011 examined how 340 patients with rheumatoid arthritis, or RA, reacted to the H1N1 flu vaccine compared to 234 healthy patients. The researchers discovered that 60 percent of the RA patients had enough antibodies to be considered protected, compared to almost 83 percent of the healthy controls – a 20 percent difference. Taking methotrexate – but not other disease modifying anti-rheumatic drugs, or DMARDs, including anti-TNF – was associated with less protection.  When it came to disease activity, just 2.6 percent of patients or nine people said their symptoms worsened after taking the vaccine.

Patricia Winokur, MD, a professor of internal medicine at the University of Iowa’s Carver College of Medicine, in Iowa City, who was not involved with the study, says 2.6 percent is a relatively small number of people who had worsening disease activity. She says it’s so small, it’s hard to know whether it happened because of the RA or the vaccine. But she says the bottom line is, the vaccine still had an effect, even if it is reduced. “I think the big picture for patients is, though they may not respond as well as a healthy population, they are still responding and should still get the vaccine,” Dr. Winokur explains.

Lupus

A second study, published online in Arthritis & Rheumatism in May 2011, explored which lupus patients were more likely to respond well to the traditional flu vaccine and what factors were involved..

Researchers led by Judith A. James, MD, PhD, chair of the Arthritis & Clinical Immunology program at Oklahoma Medical Research Foundation, collected blood samples and details about disease activity from 72 lupus patients and 72 healthy people prior to getting vaccinated and again at two, six and 12 weeks afterward. The researchers compared antibodies and other blood markers between the two groups. They found that, overall, lupus patients did not have as strong of a response to the vaccine as healthy controls, however, some lupus patients made close-to-normal responses – and were dubbed “high responders.”

The researchers say one of their more surprising discoveries was that African-Americans with lupus were three times more likely than those of European decent to be high responders, although they aren’t sure why this is.

“Because a lot of lupus patients with severe disease are likely to be African American, I was afraid they were on more aggressive drugs and might not have as good a response. But we found they did well and should be encouraged to take the vaccine,” says Dr. James, who is also a professor of medicine at the Oklahoma University Health Science Center in Oklahoma City and a practicing rheumatologist.

Patients with lupus who didn’t respond as well to the vaccine – so-called “low responders” – had a greater number of active lupus symptoms, were more likely to have blood disorders from lupus and were more likely to be taking prednisone when they were vaccinated. They were also more likely to experience a flare after the vaccination. Dr. James says despite these findings, the overall message for the majority of lupus patients is: It is safe and advisable to take the flu vaccine, as long as it’s not the live form.

“We were somewhat surprised to find out that most of the medicines [lupus patients] were on, and the doses they were on, didn’t impair their ability to make an effective response,” Dr. James explains. “We have always worried that people with these diseases won’t have effective responses to vaccines or that the vaccine will cause the disease to flare. But what we found was, it is safe in the majority of patients. Almost none of the patients we saw had severe disease flares. They were usually mild to moderate disease flares and they may have had those anyway. That’s the problem with lupus. It waxes and wanes and you don’t know if it’s due to the flu shot or if it [would] flare anyway.”

Bottom Line

Flu and other infectious diseases are a leading cause of illness and death among people with lupus and RA. And while not all patients respond well to vaccines, Dr. James says overall vaccines do help reduce risks, which is important when you’re trying to help patients protect themselves in any safe way they can.

“Most of our patients who are on certain kinds of medications aren’t candidates for live vaccines, but for all other vaccines, they might be good candidates to try and create protective responses so we can decrease infection rates and the severity of infections in our patients,” Dr. James explains. “A lot of our patients worry the flu shot will give them the flu. It won’t. It may make your arm sore or make you feel not great for 24 hours. But if it keeps you from getting hospitalized or makes the flu symptoms milder, that’s important. Flu still kills people.”

Dr. James also stresses that patients should be having a discussion about flu shots and other vaccines not just with their rheumatologist but also with their primary-care provider, because they are the ones who most often administer vaccines.

“A lot of times primary-care doctors have very short periods of time with patients and our patients are complicated,” Dr. James says. “So make sure your doctor knows what medications you are taking.”

Dr. Winokur says patients should also know that there are ongoing studies trying to get even more clarification on this issue for patients. She and a team from the University of Iowa are starting a study this fall to see if 80 RA patients – who will be compared to 80 healthy patients of similar ages – respond differently or better to the new high-dose influenza vaccine approved to treat the elderly.

“It’s a strategy that’s very effective for the elderly, who respond much less well to [traditional] flu vaccines and it’s improved their response. The question is, would it also be true in this type of population,” Dr. Winokur asks.