[CIS PIDD] [cis-pidd] Immunology question

[CIS-PIDD]

Dr. Church:

I have no first-hand knowledge myself.  But, based on the literature, there is some evidence that patients on sirolimus would respond to the dead vaccines (Willcocks et al., Am J Transplant 2007), though the live vaccines may cause breakthrough infection (Levitsky et al., Am J Transplant 2002).  A systematic review on solid organ transplant patients (Eckerle et al., PLoS One 2013) -- so, the population most likely to be on siro/evero/tacrolimus -- suggests that efficacy to the live vaccines is probably fine, but there is insufficient data on safety.  The Infectious Diseases Society of America's guidelines on vaccination of immunocompromised patients (L Rubin et al., Clin Infect Dis 2013) does not address your specific concern -- they emphasize vaccinating SOT and HSCT candidates >= 4 weeks prior to immunosuppression, and vaccinating after immunosuppression is discontinued.  

Probably the closest recommendation:

  "103. MMR vaccine and VAR should generally not be administered to SOT recipients because of insufficient safety and effectiveness data (strong, low), except for varicella in children without evidence of immunity (as defined in recommendation 15) who are renal or liver transplant recipients, are receiving minimal or no immunosuppression, and have no recent graft rejection (weak, moderate).
"


The question would be what dosage of siro/everolimus, or how many weeks s/p, constitutes "minimal" immunosuppresion.  Additionally, I doubt there is any evidence out there on everolimus per se.  I would suggest extrapolating from whatever (small) evidence there may be for sirolimus.

I would recommend reaching out to the vaccine guru, Dr. Lorry Rubin (e-mail: lrubin4 at nshs.edu) -- incidentally, my Peds ID chief when I was a resident in Long Island Jewish  -- to see if he has some additional insight on this issue.

Good luck.

  - Karl

Karl O. A. Yu, M.D., Ph.D., F.A.A.P.
Instructor of Pediatrics (Pediatric Infectious Diseases)
University of Chicago - Comer Children's Hospital
5841 S Maryland Ave, MC 6054, Chicago IL 60637
Pager:  773-702-6800   x1744
Fax:  773-702-1196
Lab phone (Bubeck Wardenburg laboratory): 773-834-6976


________________________________________
From: CIS-PIDD [cis-pidd at lists.clinimmsoc.org]
Sent: Thursday, July 21, 2016 2:55 PM
To: CIS-PIDD
Subject: [cis-pidd] FW: Immunology question

Colleagues:

A patient with tuberous sclerosis has been on immunosuppressant everolimus for quite some time to treat his subependymal giant cell astrocytoma.  This is a benign brain tumor that is responsive to everolimus.

The patient’s mom would like to take him off of everolimus to give him the MMR and varicella vaccines.   His neurologist says it’s OK to take him off for “a time.”

My questions:

·         How long will the immunosuppressive effect of evrolimus last, i.e. when could he receive the live virus vaccines?

·         How long after the vaccines should they wait for immune responses to “take” before restarting the everolimus?

Thank you.

Joe Church
Children’s Hospital Los Angeles

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