Biologic Therapy Complicates Vaccination for Travel

LAS VEGAS — Solutions to several challenging treatment scenarios in patients undergoing biologic therapy for rheumatologic or dermatologic conditions were considered by a panel of experts at seminar sponsored by Skin Disease Education Foundation.

The head of the panel, Dr. Craig Leonardi, a dermatologist in private practice in St. Louis, presented one scenario in which a patient being treated with a biologic is about to travel abroad to a developing country for a brief visit and needs to get the recommended vaccinations. Among the questions he asked the panel: Should the patient get the vaccinations? If so, should he discontinue the biologic?

Discontinuing the biologic to get the vaccinations was deemed an option by the panel, but with caveats. “It depends on the agent,” said Dr. Robert Kalb of the State University of New York at Buffalo. “If the person's on etanercept, and it's a short visit, [discontinuation is] certainly a very reasonable option. [If] the person's on efalizumab, I'd be a little bit more leery. The half-life of infliximab is such that, depending on the timing of the infusion, you might be able to get away with it.” He noted that he advises continuing the biologic during vaccinations that use killed vaccine and thus there is no reason to stop therapy for influenza or pneumonia vaccinations.

Dr. Bruce Strober of New York University, New York, said that stopping the biologic makes it more likely the vaccine will be at its peak efficacy. “I think there are some tangential studies that show if you give some types of vaccines in the midst of biologic therapy, some immunologic readouts are reduced, but the clinical relevance of that hasn't been established.” He noted that live vaccines are contraindicated with biologics. As to the length of time for biologic discontinuation in the setting of live vaccine use, “you would like the biologic to be more or less inactive in the patient, so four to five half-lives,” he said.

This estimate was shared by panelist Dr. Francisco Kerdel of Cedars Medical Center in Miami, who also raised the question of whether biologic treatment brings an increased risk of contracting disease, especially in regions with a greater number and variety of nefarious microbes. “When you talk about the granulomatous diseases being activated by the use of anti-[tumor necrosis factor], most of the time it applies to patients reactivating what they already have,” he said.

Dr. Strober suggested that physicians ask patients taking biologics about their future travel plans and vaccinations.

Flare-up of the disease itself is one of the foremost risks of stopping a biologic, especially efalizumab, Dr. Leonardi noted. Disease rebound is less of a risk, however, with TNF-α antagonists.

Another challenging scenario that Dr. Leonardi presented involved an elderly patient with psoriatic arthritis and heart failure (HF) who is unwilling to accept conventional treatment and insists on biologic therapy.

“I think you need to define the severity of HF,” Dr. Strober said, adding that studies of etanercept and infliximab showed that only patients with very severe heart failure experienced problems on infliximab, and only on the highest dose of 10 mg/kg. He advised consulting with a cardiologist to determine if tumor necrosis factor inhibitors are an option. Even so, he suggested trying efalizumab or alefacept first.

The panel also discussed the issue of weight and body mass index with biologic therapy. Morbidly obese patients don't respond as well to etanercept, Dr. Kalb noted, but the biologics with weight-based dosing, efalizumab and infliximab, have demonstrated similar responses in patients with and without high body mass index. Part of the difficulty in treating heavier patients may lie in weight-based dosing.

The final scenario presented involved a patient on a biologic who is about to undergo elective surgery for chronic cholecystitis refractory to antibiotics. Dr. Leonardi advised stopping the biologic and restarting it after surgery, except in the case of etanercept. Biologics might pose some effect on postsurgical wound healing and infection risk, but little is known about such interactions, Dr. Kerdel said.

It is important, however, to tell the surgeon what biologic the patient is taking, Dr. Leonardi said. “The surgeon may have no idea what these medicines are,” he said.

Dr. Kalb noted that many patients with Crohn's disease need surgery and that many continue taking infliximab.

Dr. Kerdel noted that if the cholecystitis patient is taking efalizumab, “I would continue [treatment], because I think the risk of having a rebound phenomenon … would be greater than the risk of infections that we know of.”

Dr. Leonardi is a consultant for Amgen, Abbott, Genentech, and Centocor. Dr. Kerdel is a consultant for Abbott, Amgen, and Centocor.

Dr. Kalb has been a consultant for the latter three firms, as well as for Genentech. Dr. Strober has received funding from, advised, or been a speaker for Genentech, Amgen/Wyeth, Centocor, Abbott, and Astellas.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

LAS VEGAS — Solutions to several challenging treatment scenarios in patients undergoing biologic therapy for rheumatologic or dermatologic conditions were considered by a panel of experts at seminar sponsored by Skin Disease Education Foundation.

The head of the panel, Dr. Craig Leonardi, a dermatologist in private practice in St. Louis, presented one scenario in which a patient being treated with a biologic is about to travel abroad to a developing country for a brief visit and needs to get the recommended vaccinations. Among the questions he asked the panel: Should the patient get the vaccinations? If so, should he discontinue the biologic?

Discontinuing the biologic to get the vaccinations was deemed an option by the panel, but with caveats. “It depends on the agent,” said Dr. Robert Kalb of the State University of New York at Buffalo. “If the person's on etanercept, and it's a short visit, [discontinuation is] certainly a very reasonable option. [If] the person's on efalizumab, I'd be a little bit more leery. The half-life of infliximab is such that, depending on the timing of the infusion, you might be able to get away with it.” He noted that he advises continuing the biologic during vaccinations that use killed vaccine and thus there is no reason to stop therapy for influenza or pneumonia vaccinations.

Dr. Bruce Strober of New York University, New York, said that stopping the biologic makes it more likely the vaccine will be at its peak efficacy. “I think there are some tangential studies that show if you give some types of vaccines in the midst of biologic therapy, some immunologic readouts are reduced, but the clinical relevance of that hasn't been established.” He noted that live vaccines are contraindicated with biologics. As to the length of time for biologic discontinuation in the setting of live vaccine use, “you would like the biologic to be more or less inactive in the patient, so four to five half-lives,” he said.

This estimate was shared by panelist Dr. Francisco Kerdel of Cedars Medical Center in Miami, who also raised the question of whether biologic treatment brings an increased risk of contracting disease, especially in regions with a greater number and variety of nefarious microbes. “When you talk about the granulomatous diseases being activated by the use of anti-[tumor necrosis factor], most of the time it applies to patients reactivating what they already have,” he said.

Dr. Strober suggested that physicians ask patients taking biologics about their future travel plans and vaccinations.

Flare-up of the disease itself is one of the foremost risks of stopping a biologic, especially efalizumab, Dr. Leonardi noted. Disease rebound is less of a risk, however, with TNF-α antagonists.

Another challenging scenario that Dr. Leonardi presented involved an elderly patient with psoriatic arthritis and heart failure (HF) who is unwilling to accept conventional treatment and insists on biologic therapy.

“I think you need to define the severity of HF,” Dr. Strober said, adding that studies of etanercept and infliximab showed that only patients with very severe heart failure experienced problems on infliximab, and only on the highest dose of 10 mg/kg. He advised consulting with a cardiologist to determine if tumor necrosis factor inhibitors are an option. Even so, he suggested trying efalizumab or alefacept first.

The panel also discussed the issue of weight and body mass index with biologic therapy. Morbidly obese patients don't respond as well to etanercept, Dr. Kalb noted, but the biologics with weight-based dosing, efalizumab and infliximab, have demonstrated similar responses in patients with and without high body mass index. Part of the difficulty in treating heavier patients may lie in weight-based dosing.

The final scenario presented involved a patient on a biologic who is about to undergo elective surgery for chronic cholecystitis refractory to antibiotics. Dr. Leonardi advised stopping the biologic and restarting it after surgery, except in the case of etanercept. Biologics might pose some effect on postsurgical wound healing and infection risk, but little is known about such interactions, Dr. Kerdel said.

It is important, however, to tell the surgeon what biologic the patient is taking, Dr. Leonardi said. “The surgeon may have no idea what these medicines are,” he said.

Dr. Kalb noted that many patients with Crohn's disease need surgery and that many continue taking infliximab.

Dr. Kerdel noted that if the cholecystitis patient is taking efalizumab, “I would continue [treatment], because I think the risk of having a rebound phenomenon … would be greater than the risk of infections that we know of.”

Dr. Leonardi is a consultant for Amgen, Abbott, Genentech, and Centocor. Dr. Kerdel is a consultant for Abbott, Amgen, and Centocor.

Dr. Kalb has been a consultant for the latter three firms, as well as for Genentech. Dr. Strober has received funding from, advised, or been a speaker for Genentech, Amgen/Wyeth, Centocor, Abbott, and Astellas.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

LAS VEGAS — Solutions to several challenging treatment scenarios in patients undergoing biologic therapy for rheumatologic or dermatologic conditions were considered by a panel of experts at seminar sponsored by Skin Disease Education Foundation.

The head of the panel, Dr. Craig Leonardi, a dermatologist in private practice in St. Louis, presented one scenario in which a patient being treated with a biologic is about to travel abroad to a developing country for a brief visit and needs to get the recommended vaccinations. Among the questions he asked the panel: Should the patient get the vaccinations? If so, should he discontinue the biologic?

Discontinuing the biologic to get the vaccinations was deemed an option by the panel, but with caveats. “It depends on the agent,” said Dr. Robert Kalb of the State University of New York at Buffalo. “If the person's on etanercept, and it's a short visit, [discontinuation is] certainly a very reasonable option. [If] the person's on efalizumab, I'd be a little bit more leery. The half-life of infliximab is such that, depending on the timing of the infusion, you might be able to get away with it.” He noted that he advises continuing the biologic during vaccinations that use killed vaccine and thus there is no reason to stop therapy for influenza or pneumonia vaccinations.

Dr. Bruce Strober of New York University, New York, said that stopping the biologic makes it more likely the vaccine will be at its peak efficacy. “I think there are some tangential studies that show if you give some types of vaccines in the midst of biologic therapy, some immunologic readouts are reduced, but the clinical relevance of that hasn't been established.” He noted that live vaccines are contraindicated with biologics. As to the length of time for biologic discontinuation in the setting of live vaccine use, “you would like the biologic to be more or less inactive in the patient, so four to five half-lives,” he said.

This estimate was shared by panelist Dr. Francisco Kerdel of Cedars Medical Center in Miami, who also raised the question of whether biologic treatment brings an increased risk of contracting disease, especially in regions with a greater number and variety of nefarious microbes. “When you talk about the granulomatous diseases being activated by the use of anti-[tumor necrosis factor], most of the time it applies to patients reactivating what they already have,” he said.

Dr. Strober suggested that physicians ask patients taking biologics about their future travel plans and vaccinations.

Flare-up of the disease itself is one of the foremost risks of stopping a biologic, especially efalizumab, Dr. Leonardi noted. Disease rebound is less of a risk, however, with TNF-α antagonists.

Another challenging scenario that Dr. Leonardi presented involved an elderly patient with psoriatic arthritis and heart failure (HF) who is unwilling to accept conventional treatment and insists on biologic therapy.

“I think you need to define the severity of HF,” Dr. Strober said, adding that studies of etanercept and infliximab showed that only patients with very severe heart failure experienced problems on infliximab, and only on the highest dose of 10 mg/kg. He advised consulting with a cardiologist to determine if tumor necrosis factor inhibitors are an option. Even so, he suggested trying efalizumab or alefacept first.

The panel also discussed the issue of weight and body mass index with biologic therapy. Morbidly obese patients don't respond as well to etanercept, Dr. Kalb noted, but the biologics with weight-based dosing, efalizumab and infliximab, have demonstrated similar responses in patients with and without high body mass index. Part of the difficulty in treating heavier patients may lie in weight-based dosing.

The final scenario presented involved a patient on a biologic who is about to undergo elective surgery for chronic cholecystitis refractory to antibiotics. Dr. Leonardi advised stopping the biologic and restarting it after surgery, except in the case of etanercept. Biologics might pose some effect on postsurgical wound healing and infection risk, but little is known about such interactions, Dr. Kerdel said.

It is important, however, to tell the surgeon what biologic the patient is taking, Dr. Leonardi said. “The surgeon may have no idea what these medicines are,” he said.

Dr. Kalb noted that many patients with Crohn's disease need surgery and that many continue taking infliximab.

Dr. Kerdel noted that if the cholecystitis patient is taking efalizumab, “I would continue [treatment], because I think the risk of having a rebound phenomenon … would be greater than the risk of infections that we know of.”

Dr. Leonardi is a consultant for Amgen, Abbott, Genentech, and Centocor. Dr. Kerdel is a consultant for Abbott, Amgen, and Centocor.

Dr. Kalb has been a consultant for the latter three firms, as well as for Genentech. Dr. Strober has received funding from, advised, or been a speaker for Genentech, Amgen/Wyeth, Centocor, Abbott, and Astellas.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.