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MS research update - Do flu vaccines work in people with MS and do DMTs make a difference? - 14 July 2014

Summary

People with MS are at an increased risk of catching infections and these can cause severe relapses. Vaccination is the best way to prevent some infectious diseases such as influenza (flu). The disease modifying therapies (DMTs) currently available suppress or modify the immune system. This study reviews the previous research to see if the DMT drugs have an impact on the effectiveness of flu vaccination in people with MS.

The study found that the effectiveness of flu vaccination appeared to be slightly different depending on which DMT drug was being taken but most drugs did not stop the vaccination from being protective against flu infection.

Background

People with MS are at an increased risk of catching infections and these can cause severe relapses. Vaccination is the best way to prevent some infectious diseases such as influenza (flu). This involves injecting a small amount or part of the organism that causes the infection, so the immune system mounts a reaction against it to produce antibodies. When the person comes into contact with the disease in the future, the body is already prepared, their immune system will recognise it and attack it with the antibodies, preventing infection.

The disease modifying therapies (DMTs) currently available suppress or modify the immune system. However little is known about if they prevent the body from creating the necessary antibodies in response to a vaccination, this would reduce the effectiveness of the vaccination, leaving people vulnerable to infections they thought they should be protected against.

This study reviews the previous research to see if the DMT drugs have an impact on the effectiveness of flu vaccination in people with MS.

How this study was carried out

This study was a review that assessed the previous research into vaccination effectiveness in people with MS and in those taking a DMT. The review focused on vaccination against flu as there is very little research on other types of vaccinations.

The review included studies investigating flu vaccination in people with MS not taking a DMT and in people with MS taking one of nine DMT drugs that are licensed in the USA. As many of the DMT drugs work through different ways in the body the authors did separate analysis of the evidence for each drug.

What was found

The study found that the effectiveness of flu vaccination appeared to be slightly different depending on which DMT drug was being taken but most drugs did not stop the vaccination from being protective against flu infection.

People with MS not taking a DMT

Three studies were assessed. The review found that flu vaccination was effective in people with MS not taking a DMT and protected them.

Beta-interferon (Betaferon, Extavia, Avonex and Rebif)

Three studies were assessed, two compared people with MS and healthy controls and the third compared people with MS taking or not taking beta interferon. Together these studies compared 200 people with MS treated with beta interferon and 500 healthy or untreated MS controls, and found that flu vaccination was effective in both groups.

Glatiramer acetate (Copaxone)

There was only one study available looking at flu vaccination in people with MS taking glatiramer acetate. The results suggested that vaccination may offer them less protection from the flu than it should, but as this was the result from one small study, more work in a larger number of people is needed.

Mitoxantrone

There was one study assessed. It found that none of the 11 mitoxantrone treated people with MS were protected by the flu vaccination they received against the H1N1 strain of flu. Although this was a result from a very small number of people it suggests mitoxantrone interferes with the effectiveness of the vaccine. As mitoxantrone is a powerful suppressor of the immune system this is not an unexpected result but further studies would be needed to validate the results from this small study.

Natalizumab (Tysabri)

Two studies were assessed, both compared people with MS and healthy controls. The two studies found different results, one found less protection against the flu in people with MS treated with natalizumab and the other found no difference in the level of protection. However both studies were in a small number of people, so larger studies would be needed to work out which result is correct.

Fingolimod (Gilenya)

One study compared 14 people with MS taking fingolimod and 18 healthy controls and found that flu vaccine effectiveness was similar between the two groups. As this was a small study, studies in a larger number of people would be needed to confirm the result.

Teriflunomide (Aubagio)

One study looking at 128 people with MS taking teriflunomide found that the flu vaccination was effective and most people were protected against flu. Further studies would be helpful to confirm the result.

What does it mean?

The study found that although DMTs affect the immune system, most of the drugs did not significantly change the effectiveness of flu vaccination, which protects people with MS from catching flu. As there was only a small amount of research for some of the DMTs the authors suggest further studies are needed to confirm the impact of these on the effectiveness of flu vaccination.

The authors suggest that for people taking DMTs where flu vaccination was only partially effective and protective, a second booster vaccination potentially may help to provide full protection against the flu, but that would need to be tested in studies to see whether this does actually boost the effectiveness.

Comment

Although the authors classify mitoxantrone as a DMT in this study, it is not routinely prescribed as a DMT in the UK. Mitoxantrone is a form of chemotherapy that is licensed in some other countries as a treatment for multiple sclerosis. In the UK it is only licensed as a cancer treatment, although it is occasionally used in some specialist MS centres to treat people with aggressive forms of relapsing remitting MS with very frequent and severe relapses or people with secondary progressive MS where relapses are still a significant feature.

Pellegrino P, Carnovale C, Perrone V, et al.
Efficacy of vaccination against influenza in patients with multiple sclerosis: The role of concomitant therapies..
Vaccine. 2014 Jul 4. [Epub ahead of print]
abstract

More about about vaccinations

In the past there has been concern over the potential effect of vaccinations on people with MS but research has failed to find evidence to support these concerns. However it is known that infections can trigger relapses in people with MS. Therefore the NICE MS Guideline states that there is no reason why people with MS should not have all the vaccinations that are required both for use in the UK and when travelling abroad. People with MS are one of the groups offered the annual flu jab every autumn by the NHS. As flu can be a severe infection that can cause worsening MS symptoms, trigger a relapse or result in some potentially serious health complications, vaccination is recommended for people with MS to protect them against the common strains of flu that are circulating in the general population that year.

For most people with MS it's preferable to be protected than run the risk of contracting the diseases, many of which are serious and life threatening or can have a major impact on their MS. There are certain exceptions and situations where people should not receive vaccinations. If the person is currently unwell vaccination is usually delayed to a time when the person is better again. If someone is taking a drug that suppresses the immune system, such as chemotherapy or steroids, then they should not receive 'live' vaccines as they may be at greater risk for developing the disease.

You can read more about vaccinations and MS in the A to Z of MS.

You can read more about the seasonal flu vaccination available on the NHS on the NHS Choices website.

Research by topic areas...

Assessment tools

Bosma L, Sonder J, Kragt J, et al.
Detecting clinically-relevant changes in progressive multiple sclerosis.
Mult Scler. 2014 Jul 10. [Epub ahead of print]
abstract

Gielen J, Laton J, Van Schependom J, et al.
The squares test as a measure of hand function in multiple sclerosis.
Clin Neurol Neurosurg. 2014 May 20;123C:55-60. [Epub ahead of print]
abstract

Papathanasiou A, Messinis L, Georgiou VL, et al.
Cognitive impairment in relapsing remitting and secondary progressive multiple sclerosis patients: efficacy of a computerized cognitive screening battery.
ISRN Neurol. 2014;2014:151379.
abstract
Read the full text of this paper

Physical activity

Marck CH, Hadgkiss EJ, Weiland TJ, et al.
Physical activity and associated levels of disability and quality of life in people with multiple sclerosis: a large international survey.
BMC Neurol. 2014 Jul 12;14(1):143. [Epub ahead of print]
abstract
Read the full text of this paper (PDF)

Sandroff BM, Pilutti LA, Benedict RH, et al.
Association between physical fitness and cognitive function in multiple sclerosis: does disability status matter?
Neurorehabil Neural Repair. 2014 Jul 8. [Epub ahead of print]
abstract

Guerra E, di Cagno A, Mancini P, et al.
Physical fitness assessment in multiple sclerosis patients: A controlled study.
Res Dev Disabil. 2014 Jul 5;35(10):2527-2533. [Epub ahead of print]
abstract

psychological aspects

Crescentini C, Urgesi C, Fabbro F, et al.
Cognitive and brain reserve for mind-body therapeutic approaches in multiple sclerosis: A review.
Restor Neurol Neurosci. 2014 Jul 11. [Epub ahead of print]
abstract

Johansson V, Lundholm C, Hillert J, et al.
Multiple sclerosis and psychiatric disorders: Comorbidity and sibling risk in a nationwide Swedish cohort.
Mult Scler. 2014 Jul 10. [Epub ahead of print]
abstract

Van Schependom J, D'hooghe MB, Cleynhens K, et al.
Reduced information processing speed as primum movens for cognitive decline in MS.
Mult Scler. 2014 Jul 10. [Epub ahead of print]
abstract

Ukueberuwa DM, Arnett PA.
Evaluating the role of coping style as a moderator of fatigue and risk for future cognitive impairment in multiple sclerosis.
J Int Neuropsychol Soc. 2014 Jul 7:1-5. [Epub ahead of print]
abstract

Quality of life

Ploughman M, Beaulieu S, Harris C, et al.
The Canadian survey of health, lifestyle and ageing with multiple sclerosis: methodology and initial results.
BMJ Open. 2014 Jul 10;4(7):e005718.
abstract
Read the full text of this paper

Rehabilitation

Elisabet NY, Lena Kristina VK, Malin N, et al.
Balance exercise program reduced falls in people with multiple sclerosis - a single group pretest posttest trial.
Arch Phys Med Rehabil. 2014 Jul 5. [Epub ahead of print]
abstract
Read the full text of this paper (PDF)

Symptoms and symptom management

James R, Frasure HE, Mahajan ST.
Urinary catheterization may not adversely impact quality of life in multiple sclerosis patients.
ISRN Neurol. 2014;2014:167030.
abstract
Read the full text of this paper

Balantrapu S, Sosnoff JJ, Pula JH, et al.
Leg spasticity and ambulation in multiple sclerosis.
Mult Scler Int. 2014;2014:649390.
abstract
Read the full text of this paper

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