Patients with inflammatory rheumatic diseases have much greater risk of infection than the general adult population. Those with rheumatoid arthritis have between two and five times the risk compared with other adults. Infection kills as many people as active disease in the first five years of systemic lupus erythematosis (SLE), and it causes 30% of all deaths in patients with SLE or vasculitis. The infections are the common ones.
Risk increased due to
- Use of immunosuppressive drugs
- Patients with rheumatoid arthritis or SLE have increased susceptibility to infection.
- Active inflammation also increases the risk of infection.
- Use of corticosteroids increase the risk of infection in a dose-dependent manner.
- Poor nutrition, frailty, end organ damage and poverty.
Measles and chickenpox
All infections are more common in patients who have rheumatic diseases, but the increase is greatest for diseases such as measles and chickenpox.
Although anticipated disease-modifying anti rheumatic drugs (DMARDs) such as methotrexate and leflunamide( Arava) are generally not associated with increased infection risk. Taken together, the data suggest that active disease and corticosteroids raise the risk of infection more than the traditional DMARDs.
Biological drugs the TNF blockers, such as Embrel, Hunira & Remicade which are a new class of medication are associated with increased risk of tuberculosis and an increased tendency to soft tissue infections as the main infectious complications.
- Decrease arthritis activity and inflammation
- General health promotion such as exercise, nutrition and smoking cessation.
- Immunisation reduces the risks of contracting common infections without exposing patients or pathogens to antibiotics.
How safe are the vaccines?
There is no evidence in any of the available trials that influenza or pneumococcal vaccines cause disease flare in rheumatoid arthritis or SLE .
What does it mean for practice?
- Immunisation in patients with rheumatic diseases is safe as long as live vaccines are avoided.
- All killed and inactive vaccines can be used as normal.
- If possible, any vaccinations should be given before beginning immunosuppression.
- The guidelines in The Australian Immunisation Handbook are quite explicit in stating that all patients with rheumatoid arthritis and SLE should be given influenza vaccine (Fluad, Fluarix, Fluvax, Influvac, Vaxigrip) and pneumococcal vaccine (Pneumovax 23)
- Influenza vaccine should be given annually.
- Pneumococcal vaccine should be given once.
- Meningococcal vaccine (Mencevax ACWY, Meningitec, Menjugate, Menomune, NeisVac-C) is recommended for patients who are at risk and for patients with no spleen.
Immunosuppression is thought to occur in patients with chronic inflammatory rheumatic diseases and in patients receiving immunosuppressive drugs or corticosteroids. Infection is the greatest risk to these individuals. There is no evidence that vaccination causes a disease flare. Immunisation should be offered to these individuals unless a contraindication is present.