Regular vaccinations for most MS patients recommended by experts

People with multiple sclerosis (MS) should generally follow a regular vaccination schedule similar to their healthy peers, with certain adjustments made if they’re on particular disease-modifying therapies (DMTs), according to a group of experts in Europe who devised a set of more than 50 evidence-based guidelines for the safe and effective use of vaccines in MS.

The efforts were spearheaded by the European Commission for Treatment Research in Multiple Sclerosis (ECTRIMS) and the European Academy of Neurology (EAN).

The guidelines were published in a consensus statement, titled “European Committee for Treatment and Research in Multiple Sclerosis and European Academy of Neurology Consensus on Vaccination in People with Multiple Sclerosis: Improving Immunization Strategies in the Era of Highly Active Immunotherapeutic Drugs.”

It was published in the Multiple Sclerosis Journal as well as the European Journal of Neurology.

Consensus statement a ‘landmark achievement’ for MS community

“The publication of this consensus statement is a landmark achievement for the multiple sclerosis community,” Mar Tintoré, MD, PhD, ECTRIMS president, said in an ECTRIMS press release.

The statement marks the first European consensus on vaccination in people with MS, the release stated.

“ECTRIMS is proud to present this evidence-based guidance, which will serve as a valuable resource for healthcare professionals, patients, and their families,” Tintoré added. “We believe that by implementing these recommendations, we can optimize vaccination strategies, minimize risks, and ensure the best possible outcomes for individuals with MS.”

An autoimmune disease, MS is characterized by the immune system’s self-reactive attacks on myelin, the fatty substance that surrounds and protects nerve cells, leading to neuroinflammation and neurodegeneration.

To combat these attacks, new DMTs typically involve some type of immunosuppression. While proven highly effective at easing symptoms and improving prognosis, such treatments can also leave patients vulnerable to infections that the immune system would normally fight off.

“An important part of the infectious risks for [people with MS] receiving highly active immunotherapies can be mitigated through vaccination,” the researchers wrote.

Still, a number of questions remain as to how vaccinations should be managed in this patient population, including when and whether to administer a vaccine, and which specific DMTs might influence how effective a vaccine is.

Moreover, “vaccine coverage rates have been reported to be lower than desired for MS populations,” the researchers wrote.

Led by ECTRIMS and EAN, a multidisciplinary group of MS and vaccine experts, as well as a patient representative, has now convened to recommend the best practices for immunization in MS patients.

“The core spirit of a joint ECTRIMS-EAN consensus is to afford ‘one voice’ on behalf of all parties concerned,” said Thomas Berger, MD, EAN’s scientific committee chair.

We believe that by implementing these recommendations, we can optimize vaccination strategies, minimize risks, and ensure the best possible outcomes for individuals with MS.

Guidelines based on analysis of studies related to vaccinations

The expert committee addressed key questions covering topics such as vaccine safety and effectiveness, global vaccination strategy, and vaccination in specific subgroups of MS patients. The resulting guidelines were based on an evidence-based analysis of existing studies related to vaccinations in this patient population.

While the consensus guidelines were extensive — amounting to 53 recommendations — a few key points were emphasized.

Vaccines are not linked to an increased relapse or disability progression risk in MS patients, regardless of DMT use, and “the benefit of immunization greatly outweighs any potential risks,” the experts wrote.

As such, the committee recommended that doctors should evaluate a patient’s immunization status and come up with a plan that involves vaccinations as soon as possible after an MS diagnosis.

Generally, children, adults, pregnant women, and elderly adults with MS should follow a regular vaccine schedule similar to the general population, including yearly flu and pneumococcal vaccines. Vaccines should be avoided during an active disease relapse, the committee noted.

Certain vaccines might be indicated or contraindicated depending on a person’s prescribed DMTs, as the production of antibodies in response to a vaccine — an indicator of its effectiveness — is lower with use of certain DMTs.

These include anti-CD20 therapies (e.g. Ocrevus, Briumvi, and Kesimpta), S1P modulators (e.g. Gilenya, Mayzent, Ponvory, and Zeposia), and possibly Lemtrada (alemtuzumab) or Mavenclad (cladribine).

Live-attenuated vaccines should generally be avoided with certain MS therapies

Moreover, while inactivated vaccines, or those containing viruses that are dead and cannot multiplicate or cause infection, can generally be used at any time in all patients, live-attenuated vaccines may have more limitations.

Such vaccines, which contain a weakened form of a virus that can still grow but doesn’t cause illness, should be given at least a month before starting DMTs or after steroid treatment.

Live-attenuated vaccines should generally be avoided when using therapies including Aubagio (teriflunomide), Tysabri (natalizumab), Tecfidera (dimethyl fumarate), anti-CD20 therapies, and S1P modulators.

“As more evidence becomes available regarding the long-term impact on the risk of infections of the new highly effective drugs available for treatment in [people with MS], changes in vaccination recommendations might occur,” the researchers wrote.

In particular, the COVID-19 pandemic and the rapid development of new types of vaccines has provided a large amount of data on this issue in a short amount of time.

“This information on the infection–vaccination–immunity triad will likely lead to more studies to update future guidelines,” the team concluded.