Assessing MG Patients’ Meningococcal Vaccine Status

Key Takeaways:

• Vaccine status should be confirmed at the time of diagnosis and carefully considered in the context of planned or ongoing immunosuppressive treatments.
• Patients should adhere to recommended vaccine schedules and booster guidelines and be vigilant in monitoring for symptoms of meningococcal disease.
• The meningococcal vaccine is critical for patients receiving complement inhibitors such as eculizumab (Soliris®) and ravulizumab (Ultomiris®).

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease characterized by fluctuating weakness of voluntary muscles. Management often involves immunosuppressive therapies to modulate the autoimmune response. While these treatments are crucial for disease control, they increase the risk of infections, including those caused by Neisseria meningitidis, the bacterium responsible for meningococcal disease.¹

Therefore, a comprehensive assessment of meningococcal vaccine status is paramount in MG patients. Ideally, vaccine status should be confirmed at the time of diagnosis and carefully considered in the context of planned or ongoing immunosuppressive treatments.²

The heightened risk of meningococcal disease in MG patients

Patients with MG, particularly those receiving complement inhibitors such as eculizumab (Soliris®) or ravulizumab (Ultomiris®), are at increased risk for meningococcal disease. These drugs target and inhibit components of the complement system, a vital part of the innate immune response responsible for clearing Neisseria meningitidis bacteria. Even with vaccination, the risk of meningococcal infection is not eliminated in this patient population, necessitating a high index of suspicion for disease symptoms.^1,2

Beyond complement inhibitors, generalized immunosuppression from drugs such as prednisone, azathioprine, or mycophenolate can also compromise a person’s ability to mount an effective immune response against various pathogens, including N. meningitidis.¹

Meningococcal disease can manifest as meningitis, septicemia, or both, leading to severe morbidity and mortality. Symptoms can be non-specific initially, including:⁴

• Fever
• Headache
• Stiff neck
• Nausea
• Vomiting
• Confusion
• Rash

Timing of assessment and vaccination

The ideal time to assess an MG patient's meningococcal vaccine status is at the earliest possible opportunity, preferably at diagnosis. This allows for the timely administration of vaccines before starting immunosuppressive therapies.^1,2

The Advisory Committee on Immunization Practices (ACIP) strongly recommends meningococcal vaccination for those at an increased risk, including those with complement deficiencies or receiving complement inhibitors.²

For those starting complement inhibitor therapy, it is recommended that both MenACWY (quadrivalent meningococcal conjugate vaccine protecting against serogroups A, C, W, and Y) and MenB (serogroup B meningococcal vaccine) series be completed at least 2 weeks before the first dose of the complement inhibitor.²

This 2-week window allows for the development of a protective immune response. If urgent treatment with a complement inhibitor is necessary and vaccination is not up to date, antibiotic prophylaxis should be considered, and meningococcal vaccination should be administered as soon as possible.^1,2

Implications of treatment timing and ongoing monitoring

The dynamic nature of MG treatment regimens further emphasizes the need for continuous assessment and appropriate vaccination. Patients may transition between different immunosuppressive agents, each with varying degrees of immunocompromising effects.^1,2

For instance, a patient starting on a low-dose steroid may later require escalation to higher doses or the addition of a biologic agent, necessitating a re-evaluation of their vaccine needs.

Booster doses are also a critical consideration. For MG patients receiving complement inhibitors, MenACWY booster doses are recommended every 5 years for the duration of therapy, while MenB booster doses may be required every 2 to 3 years, depending on the specific vaccine product and ongoing risk.^1,2

Healthcare providers (HCPs) should track vaccination records and anticipate booster needs to maintain continuous protection. Furthermore, HCPs should educate patients and their caregivers about the increased risk of meningococcal disease, its symptoms, and the importance of seeking immediate medical attention if any symptoms develop, even if the patient has been vaccinated.

Vaccination reduces the risk but does not eliminate it. Clinicians must maintain a high index of suspicion for meningococcal disease in this vulnerable population.^1,2

Assessing and addressing the meningococcal vaccine status of MG patients is a critical component of their comprehensive care. Proactive vaccination at diagnosis, adherence to recommended schedules and booster guidelines, and vigilant monitoring for symptoms of meningococcal disease are essential to mitigate the risks associated with an already vulnerable patient population.

The decision to vaccinate should always involve a careful risk-benefit analysis, considering the patient's current disease activity, immunosuppressive regimen, and overall health status. Collaboration between neurologists, HCPs, and infectious disease specialists can optimize vaccine strategies and patient outcomes.