Sam L Lam, PharmD, on Vaccines for Patients With Liver Disease

In this video, clinical pharmacist Sam Lam discusses the types and timing of vaccines among patients with liver disease.

Sam Lam, PharmD, is a clinical pharmacist with the Liver Center at Beth Israel Deaconess Medical Center in Boston, Massachusetts.

TRANSCRIPT:

Sam Lam:  Hello, everyone. My name is Sam. I am a clinical pharmacist. I work out from Beth Israel Deaconess Medical Center at the Liver Center. I wanted to give a short presentation today with regards to vaccination and its importance to people with liver conditions.

As we all know, vaccinations are especially critical and important for people with health conditions such as liver disease. Liver disease varies from conditions, such as fatty liver, viral Hepatitis, whether it is active or has resolved. Autoimmune closed static conditions such as autoimmune hepatitis, PBC, or PSC.

Patients with advanced fibrosis or cirrhosis, and they even include our pre or post-liver transplantation patients. In many of these instances, patients are treated with one, if not multiple, immunosuppressants. Some of the common ones used with our transplant patients, as well as our autoimmune hepatitis patients.

Include steroids such as prednisone, antimetabolites like azathioprine, mycophenolate, as well as calcineurin inhibitors such as tacrolimus. In our clinical setting, vaccination status should be reviewed and updated periodically, and ideally prior to their institution of immunosuppressant therapy.

Live, attenuated vaccines are not recommended in persons on high doses of immunosuppressions, whereas recombinant and inactivated vaccines are considered safe. Even in the case of post-cell organ transplantations. Response rates to vaccines are lower in immuno-suppressed patients, but not so low as to preclude their use.

I want to note some of the common vaccines that are live vaccines such as the MMR vaccines, and the varicella, or the chickenpox vaccine. We want to make sure we avoid these in patients who are on high doses of immunosuppressants or if they are posttransplantations.

I really want to bring our focus to a list of inactivated vaccines that are recommended by the CDC, that are also in-lined with their AASLD guidance. Some of the common vaccines include the Tdap vaccines, the pneumococcal vaccine, zoster vaccine.

In this case, we would always recommend their recombinant formulation which is a Shingrix versus the live zoster vaccine, HPV vaccine. I wanted to put an emphasis on the following two vaccination, which is the influenza vaccine, as well as the Hepatitis A and Hepatitis B vaccination.

With regards to the influenza vaccine, in patients who are on immunosuppressive therapy, maybe they have advanced fibrosis or cirrhosis, or even post-liver transplantation. I would suggest using the high-dose influenza vaccine for all adults because it augments their immune response, and does not appear to increase the likelihood of organ rejection.

However, if in your clinical setting you are only able to carry the standard-dose vaccine, that is also a reasonable choice to provide to your patient. With regards to the COVID-19 vaccination, in our clinical setting, we recommend all our patients to be vaccinated with the COVID-19 vaccination, and that includes the booster vaccination.

With regards to the hepatitis A and the hepatitis B vaccine, which are two viral hepatitis vaccine that is available, we should always check a full hep A and hep B serology. For patients who are nonimmune or unprotected against infections with hepatitis A virus and hepatitis B virus, they should undergo vaccination.

Again, ideally prior to immunosuppressive treatment, if possible. It has been demonstrated in the autoimmune liver disease population that susceptibility to hepatitis A infection is as high as 51%, and susceptibility to the hepatitis B virus infection in this population is as high as 86%.

When we give these patients the hepatitis A and the hepatitis B vaccine, protective antibodies have developed in all patients vaccinated for hepatitis A, and in up to 76% of patients who were vaccinated for hepatitis B. Really, vaccination failures are mainly attributed to concomitant use of immunosuppressive therapy.

Really, in conclusion, vaccine-preventable infections such as influenza, hepatitis A, and hepatitis B is a very, very important part of a patient's liver medical care. Vaccines should be administered as early as possible. Ideally, again, before the initiation of immunosuppressants when the likelihood of developing a protective immune response is highest.

Also, this is the time when live vaccine can be given safely. Again, all patients who have any liver conditions including solid organ transplant candidates and recipients should be screened for hepatitis A virus and hepatitis B virus serologies.

For those who are not immune, vaccinations should be provided because they are at an increased risk for full immune hepatic failures from these viruses.

Thank you.