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Musculoskeletal steroid injection and concurrent influenza vaccination - analysis of current evidence, PCRMM

Best Practice Bulletin: Edition 7

17 Feb 2021

Musculoskeletal steroid injection and concurrent influenza vaccination - analysis of current evidence, PCRMM

Musculoskeletal steroid injection and concurrent influenza vaccination - analysis of current evidence, PCRMM

Some clinicians are happy to deliver joint corticosteroid (CS) injections and influenza vaccination simultaneously. In contrast, others choose to postpone either procedure due to concerns that the CS injection may weaken vaccine effectiveness.

Influenza causes significant morbidity and mortality (Lambert and Fauci, 2010). However, its prevalence can be reduced through yearly vaccination (Nichol et al., 2007). Consequently, postponing the vaccination may risk influenza infection, especially if the patient fails to re-attend for vaccination.  The Advisory Members of Primary Care Rheumatology and Musculoskeletal Medicine Society wanted to demonstrate whether the CS dose used in musculoskeletal (MSK) injections is enough to reduce the immune response to influenza vaccination to a clinically significant degree.

The library service at East Lancashire Hospitals NHS Trust conducted a literature search to identify relevant evidence by using broad headings and search terms across EMBASE and MEDLINE. A secondary search identifying studies researching CS administration by whatever route and the effect on influenza vaccine response was subsequently completed due to limited studies investigating only CS injection and influenza vaccination. The rational being that this information could then be applied from the analysis of the effects of systemic CS on vaccination effectiveness. Over 500 studies were identified. Most analysed immunosuppressive drugs other than steroids. The author selected 8 of the sourced studies which met the inclusion criteria for analysis. These studies generally concentrated on antibody production post influenza vaccination.

Six out of eight analysed studies, which met the inclusion criteria, indicated that systemic corticosteroids do not impact on immune responses to the influenza vaccination (De Roux, et al., 2006; Inoue, et al., 2013; Fairchok, et al., 1998; Kubiet, et al., 1996; Hanania, et al., 2004; Park, et al., 1996). One study was unable to provide a conclusion about CS therapy as multiple immunosuppressive treatments were compared (Agarwal, et al., 2012). One study indicated increased relative risk (1.52) for influenza infection (Sytsma, et al., 2018), however due to poor study design no valuable conclusion could be drawn for clinical practice.

Some challenges were found in interpreting these studies. Firstly, as influenza vaccine contains antigens from a few virus strains which change on a yearly basis, a patient vaccinated against a strain similar to one from a previous year may respond differently to a totally vaccine naïve patient. Moreover, the unpredictable yearly variation of circulating influenza virus can cause infection from a virus not present in the vaccine, which would then be classed as a vaccination failure (Kunisaki and Janoff, 2009). Lastly, those studies assessing vaccination effectiveness in patients using multiple immunosuppressive medications makes generating conclusions about single medications more difficult.

Nevertheless, analysis of selected studies demonstrated a lack of definite evidence that concurrent MSK CS injections alters the physiological response to vaccination against influenza. Therefore, it appears that in a population of adults and children who receive the inactivated intramuscular influenza vaccination, MSK CS injections are not contraindicated with concurrent influenza vaccination regardless of immune status.

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