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Immunosuppression and Infection in Rheumatology Patients

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Common Medications in Paediatric Rheumatology

  • Corticosteroids (Prednisone, Prednisolone, Methylprednisolone)
    Up to 1-2mg/kg/day (maximum 60mg daily)
    Pulsed IV methylprednisolone 10 - 30 mg/kg/dose (maximum 1g daily) x 3 days
  • The medications listed below have immunosuppressive effects. This depends on the agent and dose used. The disease modifying anti-rheumatic drugs (DMARDs I*) in the first column, when used singly, are considered less immunosuppressive, than those in the other three columns. 
DMARDs I* DMARDs II  Biologics  Cytotoxics 
Leflunomide (*Arava)
Azathioprine (*Imuran)
Mycophenolate mofetil 
Etanercept (*Enbrel)
Infliximab (*Remicaide) Adalimumab (*Humira)
Anakinra (*Kineret)
Rituximab (*Mabthera)

Screening prior to immunosuppressive therapy

  1. All patients
    - Serology for VZV, Measles, Hep A, B, C
    - Consider HIV
  2. Tuberculosis
    - ALL patients before biologic or cytotoxic therapy 
    - Selected patients with HIGH risk families
    - Screening tests: Mantoux, TB Quantiferon gold, CXR

Paediatric Rheumatology patients are considered significantly immunosuppressed if they are on the following medication:

  1. Prednisone 2mg/kg/day for more than 1 week, or 1mg/kg/day for more than 1 month

  2.  Medication listed in the DMARDs II, biologics or cytotoxics columns (as listed above)
    - If on combinations of DMARDs, biologics or cytotoxics 
    - If on steroids as well as single or multiple DMARDs 
  3. Clinical indications e.g. unusual and/or persistent infections

The value of additional immune testing on patients taking these medications is unknown


Vaccination pre-immunosuppression:

  • Routine immunisations, including HPV vaccine if applicable, at least TWO WEEKS prior to immunosuppression (HPV vaccine currently licensed from 9 years of age) 
  • MMR and Varicella vaccination at least ONE MONTH prior to immunosuppression, if no history of illness or VZV IgG negative 
  • Pneumococcal vaccine in SLE patients 
    - <2yrs Conjugate vaccine, as per schedule 
    - >2yrs If no prior pneumococcal vaccine, then 2 doses two months apart Prevenar (conjugate), then Pneumovax 2 months later. 
    - >2yrs If prior conjugate vaccine given as per schedule, then single dose of Pneumovax. 
    - Repeat Pneumovax every 5 years if continued immunosuppression. 
  • Influenza vaccine yearly for patient and household 

Vaccination if on immunosuppression:

  • No live vaccines (e.g. MMR, varicella, BCG), but can receive other inactivated vaccines 
  • All should receive influenza vaccine, HPV vaccine if age appropriate 
  • Meningococcal vaccines 
    - <2yr consider conjugate Men C vaccine, then when 
    - >2yrs quadrivalent meningococcal polysaccharide vaccine (A,C,Y,W135) 
    - Adolescents - advise quadrivalent meningococcalpolysaccharide vaccine (A,C,Y,W135) 

After immunosuppression, routine vaccinations (see NCCN guidelines on immunisation)

As per Starship Haematology/Oncology Immunisation policy:

  • When off therapy 6 months, check baseline immunisation titres (VZV/measles/mumps/rubella/Hep A, Hep B, diphtheria, tetanus, haemophilus B) and yearly for tetanus to consider need for booster doses
  • Commence re-immunisation schedule, provided lymphocyte count > 1.0.
  • If serology shows preservation of previous vaccine antibodies to all tested, polio/pertussis vaccines do not need to be re-administered
  • Immune globulin interferes with antibody responses to live vaccines (MMR/Varicella) only. MMR and/or varicella vaccines should be delayed until at least 6 months after measles or VZ immunoglobulin given

Antimicrobial & antifungal prophylaxis

  • Have high index of suspicion for opportunistic infections, especially if other unusual infections e.g. fungal, etc., investigate for infection and treat as appropriate
  • Evaluate on case-by-case basis

Indications for PCP Prophylaxis

  • Intravenous cyclophosphamide for juvenile dermatomyositis, SLE, vasculitides
  • Consider prophylaxis if additional other immunosuppressants, steroids
  • Consider prophylaxis depending on condition of patient e.g. pulmonary pathology
  • Routinely in Wegener's granulomatosis as on regular oral steroids and oral cyclophosphamide
  • Prophylaxis with co-trimoxazole
    - Recommended oral regimen: trimethoprim 150mg/m2 per day with sulphamethoxazole 750mg/m2 per day in divided doses twice a day, three times a week, on consecutive days e.g. co-trimoxazole 240mg BD Fri, Sat, Sun
    - If allergic to co-trimoxazole, give dapsone


  • Check Varicella zoster IgG prior to immunosuppression
    - If negative, immunise with chickenpox vaccine 1 month prior to immunosuppression
  • If IgG negative, should receive VZIG as soon as possible after exposure and can be given up to 10 days after exposure in a patient at high risk
  • If time of presentation >72 hours from exposure, consider starting acyclovir for 7 -14 days after initial contact (high dose oral or IV) after discussion with ID consultant
    - Oral acyclovir 80mg/kg/day in 4 divided doses commencing day 7 following exposure and continue for 7 days
Age  Dose Acyclovir
<2 years  200mg qid 
2-6 years  400mg qid 
>6 years  800mg qid 
  • If IgG positive, all pts who fit the definition of being significantly immunosuppressed (see above), should still receive VZIG within 72 hours of exposure and be treated with IV acyclovir if chickenpox develops (see ADHB pharmacy intranet site including medchart reference viewer)

    Significant exposure (for which VZIG indicated in susceptible patients as described above) includes the following:
    - Same household
    - Playmate - face to face indoor play or classroom
    - Same hospital room or visitors

Chickenpox and IVIG

  • Protection from IVIG and VZIG last for about 4 weeks after last infusion
  • Immunise with live vaccines ≥ 6 months after last IVIG infusion, and after 11 months if high dose IVIG used (e.g. for Juvenile Dermatomyositis, Kawasaki or ITP), otherwise likely no or poor response


  • Check Measles Ig G prior to immunosuppression. If negative, immunise with MMR vaccine 1 month prior to immunosuppression
  • If IgG negative, should receive immunoglobulin within 6 days of exposure
  • If IgG positive, all pts who fit the definition of being significantly immunosuppressed (see above) should still receive immunoglobulin within 6 days of exposure (see Measles guideline)

Measles and IVIG

  • Protection from IVIG and measles immunoglobulin last for about 4 weeks after last infusion
  • Immunise with live vaccines ≥ 6 months after last IVIG infusion, and after 11 months if high dose IVIG used (e.g. for JDM, Kawasaki or ITP), otherwise likely no or poor response

Changing immunosuppressive therapy in serious infection

  • Please discuss ALL proposed changes with Rheumatology consultant
  • If on biologic therapy e.g. Etanercept (Enbrel), stop until infection is under control. If infection suspected, then immunosuppressive should be delayed.
  • If on combinations of immunosuppressives, consider stopping one and/or increasing intervals between doses
    - If on leflunomide and severe infection, consider using cholestyramine to enhance clearance from body
  • If on chronic steroids
    - Consider reducing steroid dose if possible, but also
    - Consider HPA-axis suppression and risk of adrenal crisis. Do not discontinue steroids and ensure that patient receives stress doses, especially if fever >38°C or has operative procedure (see below)
    - Patients need IV fluids and IV hydrocortisone if not tolerating oral fluids

Corticosteroid Stress Doses

Corticosteroid Stress doses = 5 -10 times maintenance

i.e. Cortisone 50 mg/m2/day PO, or, if severe 100mg/m2/day PO or IV

Prednisone potency = 5 x cortisone potency
Continuous IV infusion of hydrocortisone is preferable to IV boluses 

Suggested doses:
Prednisone 10 mg/m2/day PO or
Hydrocortisone 100mg/m2/24hr by continuous IV infusion 

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Document Control

  • Date last published: 01 April 2010
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Rheumatology
  • Author(s): Elizabeth Wilson, Emma Best, Jackie Yan
  • Editor: Greg Williams
  • Review frequency: 2 years

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