Here is My Question:
I'm a 70 y.o. female, diagnosed with MS in my 40's. Avonex stopped d/t side effects. Amazing response to Tysabri but became JC positive so switched to Copaxone. Anaphylaxis so started Aubagio. Dropped WBC and lymphocytes so stopped. Decided no more DMT. IgG also low so started IVIG with improvement of various issues Now on IVIG every 5 weeks and maintaining. I need to get a Shingrix shot but am concerned about interaction with IVIG. This is from the CDC site: "Patients who have quantitative B-cell deficiencies and are receiving immunoglobulin therapy should not receive either non-live or live vaccines while receiving the immunoglobulin therapy because of concerns about effectiveness of the vaccines". They also state in another place to wait between the two drugs, I think it was six months but can't find that source. I know I need the Shingrix, I just don't want to decrease its effect by dosing it incorrectly. The MD's all say it doesn't matter but that doesn't seem to be true. Does anyone on this site know ?
The issue you raise concerns the effectiveness of vaccination in the setting of therapy induced immune depletion or immune modulation. This is difficult to predict based on cell counts and impossible to measure when one is receiving immunoglobulin infusions. Let me explain.
Vaccination generates both T cell and B cell immune memory, but we usually only measure the humoral immune response to the vaccine. Humoral immunity is referring to the measurement of antibodies that detect some component of the virus used in the vaccination. People who have received B cell depleting therapies (e.g., rituximab, ocrelizumab etc.) often have blunted, resting state immunoglobulin levels against the virus when tests are done to determine if they have adequate immunity post vaccination.
These tests do not measure the cell mediated immunity (T cell responses) that is critical for eradicating intracellular viruses during infection, nor do they measure the prompt ability of your body to mount an antibody response following virus exposure. This later ability is achieved by long lived memory B cells and plasma cells.
Immunoglobulin therapy has complicated effects, but for the purposes of this discussion, this therapy will make it difficult to detect your own antibodies (which are also immunoglobulins) produced by vaccination.
Because of these difficulties we use approximations to determine when to get vaccines when receiving these therapies for MS or another condition.
In the case of B cell depleting therapies, you definitely want to wait until the therapy is out of your system before getting vaccinated. In the case of Ocrelizumab and the rest of the high dose infusions that deplete B cells, this means waiting at least 3 months to get vaccinated after an infusion. Some argue to wait 6 months after an infusion to allow for some repletion of naive B cells. Clearly the longer you wait, the better the chance for an improved immune response with vaccination, but this must be balanced against the need for seasonal or yearly vaccine protection.
You could see a doctor who specializes in allergy and immunology to determine your vaccination response to make sure you have protection. While it is harder to detect T cell responses to a vaccine because of the lack of commercial assays, you can determine if your body is able to mount a prompt antibody response post vaccination by simply giving a booster injection. People with good primary immunity will quickly generate a lot of detectable antibodies after a booster, whereas this response is delayed in people who have not generated immunity.
I hope this helps.
Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
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