Vaccinations and Myasthenia Gravis: Current Recommendations

Key Takeaways:

• Most inactivated vaccines, including annual influenza, pneumococcal, Tdap, and COVID-19 vaccines, are generally safe and recommended for MG patients to prevent potentially serious infections.
• Patients receiving complement inhibitors like eculizumab and ravulizumab have a significantly increased risk of meningococcal disease and require meningococcal vaccination (both MenACWY (with boosters) and MenB), ideally before starting treatment.
• Live-attenuated vaccines should be avoided in MG patients taking immunosuppressive therapies, due to the risk of inducing infection.

Vaccination is a critical aspect of healthcare for all individuals, and it holds particular importance for patients with myasthenia gravis (MG). Due to potential immunosuppression from its treatments, MG patients are at an elevated risk of severe complications from infections that might be less threatening to individuals with healthy immune systems.^1,2

General vaccine recommendations for MG patients

Most inactivated vaccines are considered safe and are recommended for individuals with MG, even if taking immunosuppressive therapy. These include:^1,2,4

• Influenza (flu) – Annual vaccination with the inactivated influenza vaccine is strongly advised to prevent seasonal flu and its potential complications, which can trigger MG exacerbations.
• Pneumococcal – Vaccination against pneumococcal pneumonia (PCV13 and PPSV23) is recommended to reduce the risk of this serious respiratory infection.
• Tetanus, diphtheria, pertussis (Tdap) – Age-appropriate vaccination and boosters every 10 years are necessary.
• Hepatitis B – Vaccination is recommended for individuals at risk.
• Human papillomavirus (HPV) – Recommended for eligible age groups.
• Inactivated polio – Generally given in childhood, but may be administered to adults if needed.
• Non-live Shingles (recombinant zoster vaccine) – Recommended for immunocompromised individuals aged 19 and older.
• COVID-19 – Vaccination with mRNA or inactivated vaccines and recommended boosters is crucial to protect against severe COVID-19 illness, which can pose significant risks to MG patients. Studies have shown these vaccines to be generally safe in stable MG patients.

Pay special attention to live vaccines

Live-attenuated vaccines are generally contraindicated in patients receiving significant immunosuppressive therapy due to the potential risk of causing infection. These include:²

• Nasal influenza spray
• One type of shingles vaccine (live zoster vaccine)
• Measles, mumps, rubella (MMR) vaccine
• Varicella (chickenpox) vaccine
• Yellow fever vaccine

It is essential to review a patient's medication regimen and immune status before administering any live vaccine.

Meningococcal vaccine requirements for MG patients

Particular attention must be paid to meningococcal vaccination in MG patients treated or who plan to be treated with complement inhibitors such as ravulizumab (Ultomiris®). These medicines increase the risk of serious meningococcal infections because they suppress the complement system, a crucial part of the immune defense against Neisseria meningitidis.^1-3

Recommendations for patients receiving complement inhibitors

The Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommend that patients receiving complement inhibitors should receive both MenACWY and MenB vaccines:^1,3

• MenACWY – Protects against serogroups A, C, W, and Y. The initial series typically involves 2 doses at least 8 weeks apart. Booster doses are recommended every 5 years for the duration of complement inhibitor therapy.
• MenB – Protects against serogroup B. Two non-interchangeable MenB vaccines are available (Bexsero and Trumenba) with different administration schedules. For Bexsero, the primary series is 2 doses at least 1 month apart, with a booster 1 year after completion and then every 2 to 3 years if the risk persists. For Trumenba, the primary series is 3 doses (0, 1 to 2, and 6 months), with a booster 1 year after completion and then every 2 to 3 years if the risk persists.

Ideally, meningococcal vaccines should be completed or updated at least 2 weeks before the first dose of a complement inhibitor.^1,3

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.³

Healthcare providers should ensure patients and their caregivers are educated about the increased risk of meningococcal disease, its symptoms, and the importance of seeking immediate medical attention if symptoms develop, even if the patient has been vaccinated.³

Vaccination does not eliminate the risk of meningococcal disease in patients on complement inhibitors. Clinicians should maintain a high index of suspicion for meningococcal infection in these patients, even if they have been vaccinated and are receiving antibiotic prophylaxis.^1,3