Vaccinations in multiple sclerosis – current guidelines and considerations for 2025

Summary

Vaccinations in multiple sclerosis – current guidelines and considerations for 2025

Vaccination is critical for in MS, as patients who are exposed to immunosuppressive therapies or have worse disability are more susceptible to infection.

Infection increases the risk of morbidity and mortality, and is associated with MS exacerbations that may lead to more severe, sustained neurological deficit that spontaneous relapses, explained Dr Saúl Reyes, chair of Neurology at Fundación Santa Fe de Bogotá and honorary clinical lecturer at Queen Mary University of London

“We definitely do not want our patients with MS to get infections,” he said, before outlining some “general principles” for vaccination in this group.

“For patients with MS, the benefits of most vaccines greatly outweighed any potential risks, and people with MS should be capable of mounting an immune response to vaccines in a similar way to Individuals without MS, as long as they are not yet receiving any immunotherapy,” he said.

“Last but not least, the vaccination schedule should be verified and updated as soon as possible after the diagnosis of MS is suspected, to prevent any delays in the initiation of disease modifying therapies.”

Timing and precautions

As a general rule, Saúl said, inactivated vaccinations should be given at least two weeks before the initiation of disease modifying therapy (DMTs). Live vaccines are not recommended within the four weeks prior. For alemtuzumab, this increases to six weeks prior to initiation.

During immunosuppression, there may be a diminished response to inactivated vaccines, and antibody testing may be required. Live-attenuated vaccines should be avoided. After treatment discontinuation, and depending on the DMT, a period of immune restoration may be needed before administering live-attenuated vaccines.

Vaccination and DMTs

Today’s extensive MS DMT landscape has complicated the conversation around vaccination, and data is still lacking in many areas, said Saúl

What is known, he went on, is that inactivated vaccines can be used safely in people with MS who are receiving DMTS, while live attenuated vaccines should be avoided in those receiving:

• Dimethyl fumarate (DMF);

• Teriflunomide;

• S1P modulators;

• Natalizumab;

• Cladribine;

• Alemtuzumab;

• Anti-CD20 therapies.

In terms of efficacy, vaccine response in those receiving interferons or glatiramer acetate appears to similar to be the general population, and DMF teriflunomide, natalizumab; cladribine patients tend to achieve sufficient seroprotection.

In those receiving SP1 modulators and anti-CD20s, seroprotection following vaccination can be reduced, though there are limited data on the efficacy of vaccination while receiving alemtuzumab.

Current recommendations1,2,3

Saúl outlined the current recommendations for vaccination in people with MS, as set out in the ECTRIMS/EAN consensus on vaccination in people with MS, the Protecting people with MS through vaccination consensus paper, and The Green Book: Immunisation Against Infectious Disease.

These include:

• Annual seasonal influenza vaccination for all patients, as well as their immediate family and carers;

• Annual pneumococcal vaccination in the case of present or future immunosuppression, significant disability, and/or high risk of aspiration, as well as all those over the age of 65;

• Varicella in those who have never had chickenpox or who do not have a documentation of a full course of varicella zoster virus (VZV) vaccination, who test seronegative for VZV. This should be completed four weeks before initiation of immunosuppressive therapy;

• Herpes zoster vaccination should be considered in over 18s receiving immunosuppressive therapies such as cladribine, alemtuzumab, S1P modulators, natalizumab, and anti-CD20s;

• The UK’s new shingles immunisation programme applies to all immunocompetent people aged ≥65, and all immunosuppressed people aged ≥ 50;

• Measles, mumps, and rubella in seronegative patients, to be completed four weeks before initiation of immunosuppressive therapy;

• Human papillomavirus should be considered in men and women who will receive immunosuppressive therapies such as cladribine, alemtuzumab, S1 P modulator, natalizumab, and anti-CD20s;

• Hepatitis B virus vaccination in high-risk seronegative patients, especially in the case of treatment with anti-CD20 therapies;

• COVID-19 vaccination is recommended for all MS patients, especially older people and pregnant women. This includes primary immunisation and boosters.

In pregnancy, women with MS should be offered the inactivated tetanus and diphtheria vaccination any time between the 16th and 32nd week of gestation. Those who are pregnant during the flu season should be offered the inactivated influenza vaccine.

The respiratory syncytial virus is available to all pregnant women, after week 28, as well as all people over the age of 75.

As multiple sclerosis (MS) care evolves, so too does our understanding of how vaccinations impact patients living with the condition, particularly those on disease-modifying therapies (DMTs). This 45-minute webinar will provide healthcare professionals with the latest guidelines and best practices for vaccination in MS patients, highlighting key updates for 2025.

Webinar objectives

• Understand the role of vaccinations in MS care
  
• Review current vaccination guidelines
• Vaccination timing and disease modifying therapies (DMTs)
• Addressing common concerns and misconceptions
• Patient education and communication strategies