Despite advancements in lupus management over the past two decades, infection remains a significant cause of morbidity and mortality among patients with systemic lupus erythematosus (SLE).^{1 2} Various disease-related mechanisms, such as impaired neutrophil chemotaxis, lymphopenia, reduced cytotoxic T-cell activity, and hypocomplementemia due to immune complex formation, may contribute to this susceptibility. Additionally, factors related to disease activity, including hypocomplementemia, renal involvement, hypoalbuminemia, and elevated C-reactive protein levels, as well as the use of drugs, particularly glucocorticoids and conventional immunosuppressive agents, have been linked to increased risk of infection.²

Although vaccinations against pneumococcal and influenza infections are strongly recommended for all patients with rheumatic diseases, vaccination rates remain suboptimal. During the recent COVID-19 pandemic era, the importance of vaccination in these specific disease groups was better understood. Previous studies demonstrated that some immunosuppressive drugs and glucocorticoid use are associated with altered vaccine response in lupus patients.¹ During the last two decades, while the emergence of biologic agents in lupus treatment has shown promise in improving outcomes, concerns have been raised regarding their impact on vaccination effectiveness. Clinical studies involving rituximab and belimumab have highlighted this issue, with current evidence suggesting that rituximab seems to decrease antibody responses, whereas no such efficacy concerns have been reported for belimumab.^3–5 Thus, vaccination strategies for these specific patient groups should adhere to existing guidelines, considering disease activity and treatment type during assessment.

Integration of vaccination into routine care for SLE patients is imperative, given the significant role of preventable infectious complications in exacerbating morbidity and mortality. While published data suggest that vaccination efficacy may be affected by concurrent use of immunosuppressive therapy and biologic agents, a personalized approach to vaccination, weighing benefits against risks, is warranted for individual patients.

References

1. Garg M, Mufti N, Palmore TN, et al. Recommendations and barriers to vaccination in systemic lupus erythematosus. Autoimmun Rev. 2018;17(10):990–1001. doi: 10.1016/j.autrev.2018.04.006.

2. Yuan Q, Xing X, Lu Z, et al. Clinical characteristics and risk factors of infection in patients with systemic lupus erythematosus: A systematic review and meta-analysis of observational studies. Semin Arthritis Rheum. 2020;50(5):1022–39. doi: 10.1016/j.semarthrit.2020.06.004.

3. Furer V, Rondaan C, Heijstek MW, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2020;79(1):39–52. doi: 10.1136/annrheumdis-2019-215882.

4. Yıldırım R, Oliveira T, Isenberg DA. Approach to vaccination in systemic lupus erythematosus on biological treatment. Ann Rheum Dis. 2023;82(9):1123–29. doi: 10.1136/ard-2023-224071.

5. Law J, Sorrento C, Saxena A. Vaccination updates and special considerations for systemic lupus erythematosus patients. Curr Opin Rheumatol. 2024;36(2):148–53. doi: 10.1097/bor.0000000000000992.

Learning Objectives At the end of this presentation participants will be able to:

• Describe the frequency of preventable infectious complications and its importance for patients with SLE

• Identify disease and/or medication-related risk factors for increasing tendency for infection in this population

• Describe the studies regarding vaccinations and lupus in the last three decades and explore their effectiveness

• Explain the factors that affect the vaccine efficacy, especially in the setting of conventional immunosuppressive agents and biologic drugs

• Discuss the recent guidelines, delve into potential problems, and draw a future perspective on vaccination in patients with lupus