Flu Shots Not As Effective In Lupus

Flu Shots Not As Effective In Lupus
By John Gever, Senior Editor, MedPage Today
Published: July 31, 2009

WHEELING, W.Va., July 31 -- Patients with systemic lupus erythematosus showed impaired cell-mediated and antibody responses to a subunit flu vaccine, compared with healthy controls, researchers in the Netherlands found.

Following a trivalent subunit vaccination including A/H1N1, A/H3N2, and B/Hong Kong, lupus patients displayed less than half the level of gamma-interferon spot-forming cells of healthy controls, reported Albert Holvast, MD, of the University of Groningen, and colleagues in the August Arthritis & Rheumatism.

Cytokine-producing CD4-positive T cells were also less numerous in the lupus patients after vaccination, and hemagglutinin-specific antibody titers were lower, the researchers said.

The diminished cell-mediated responses appeared to be associated with prednisone and azathioprine, immunosuppressants commonly used to treat lupus.

These agents, Dr. Holvast and colleagues said, may make lupus patients less able to mount the desired antibody and cell-mediated responses to vaccination, leaving them more susceptible to infection.

"Clinicians should be aware that this combined defect might increase the morbidity and mortality due to influenza virus infection, in particular in patients receiving prednisone and/or azathioprine," they wrote.

They suggested that more effective vaccines or better vaccination strategies may be warranted for patients with lupus.

The findings were based on a prospective study of 78 lupus patients and 54 healthy age- and sex-matched controls. Fifty-four of the lupus patients were randomized to receive the flu vaccines, leaving 24 unvaccinated.

Antibody titers and cell-mediated responses to the flu strains were measured at baseline (just prior to vaccination for those receiving the vaccines) and again after four weeks.

Dr. Holvast and colleagues found that cell-mediated responses were substantially lower at baseline in lupus patients relative to controls.

Similar proportions of vaccinated participants in both groups showed increases in cell-mediated responses after vaccination. The magnitude of increase was also similar.

However, the mean absolute level of cell-mediated responses in lupus patients -- as indicated by gamma-interferon spot-producing cells in peripheral blood and the number of CD4-positive cells secreting tumor necrosis factor and interleukin-2 -- was less than half that of controls, both at baseline and after vaccination (P<0.001>

The researchers confirmed that the lupus patients' T cells were functional. Exposing them in vitro to staphylococcal enterotoxin led to strong cytokine responses similar to those seen in T cells from healthy control participants.

Earlier studies had found that antibody responses were impaired in lupus patients, and the current study confirmed those results. Antibody titers for A/H1N1 were reduced by nearly 25% (P<0.001)>P<0.01).>

But Dr. Holvast and colleagues said this was the first study to address cell-mediated immunity in lupus patients in response to flu vaccination.

Although these laboratory results suggesting impaired vaccine response weren't confirmed with live-virus challenge testing, the researchers said it was likely that patients were more susceptible to infection.

Still, the authors conceded that "there are no well-defined correlates between cell-mediated responses to influenza and the risk of influenza infection, which limits translation of our results to clinical implications."

Vaccination did not appear to worsen lupus disease activity, but the patients were more likely to report such adverse effects as itching (18% versus 2% of controls, P=0.006), erythema (24% versus 4%, P=0.003), induration at the injection site (30% versus 11%, P=0.026), and joint pain (16% versus 4%, P=0.046).

Limitations of the study included the absence of a placebo-vaccinated control group, leaving open the possibility that the findings resulted from a different type of placebo response in lupus patients versus the controls.

Other limitations included a small sample size, heterogeneous treatments among vaccinated lupus patients, and a greater number of patients in the vaccinated group who received the prior year's seasonal flu vaccine compared to controls.

Also, participants were not challenged with live flu viruses after vaccination to test their ability to resist clinical infection.

I am assuming that the above will apply to all of us on immunosuppressants.

1. We will have impaired vaccine response as we do to all vaccines including the normal flu one.
2. We are more likely to have adverse side effects to the vaccine.
3. We already know that we're not allowed live vaccines (i learnt last night that we should have finished treatment for 6 months before having a live vaccine) The nasal spray flu vaccine (for ordinary flu) contains a live virus & should be avoided.

It is adviseble to check with your doctor for recommended guidelines. In the UK anyone taking steroids are told strictly not to stop taking the tablets.

Anyone on Biologic Therapies and DMARDs are asked to stop treatment for 7 days if they come in contact with anyone suffering from Swine Flu. If they have not developed symptoms themselves after 7 days they can then restart their medication.

If anyone develops symptoms of Swine Flu they are asked to contact their doctor or helpline and consider treatment with Tamiflu. All other meds should be stopped until symptoms have gone away completely.

The swine Flu vaccination is expected to be available in the UK around September time.