There are theoretical reasons why people on anti-CD20 therapies may be at increased risk of developing cancers such as cervical cancer. This has implications for vaccination.
Really interesting to hear about this case study. Having had HPV infection and smear abnormalities in the past (CIN 1) and had recurrence with associated diathermy treatments I have luckily had clear smear tests (including a recent test showing no HPV) for a number of years. However my husband was diagnosed and successfully treated for intra-epithial penile neoplasia a while ago, suggesting that any HPV infection I might have had may be of one of the higher risk types of HPV.
However, I am now on Tysabri, but at no stage during choice of treatment options was the potential for activation of HPV discussed as a risk factor. As I might have to consider a change to another immune-suppressive DMT at some point then being aware of potential impact of previous HPV infection is worth knowing and I would certainly consider getting a polyvalent vaccine if I could.
I have had 3 ceravix vaccinations in childhood and currently have been HPV positive for 2-3 years. Do you recommend having a Gerasil-9 booster vaccination before starting my cladribine treatment and can this be given as a one off vaccination, or does it need to be administered as a series of 3 again?
This booster is said to delay starting my treatment by 4 weeks (being as a single dose of Gerasil-9). I am unsure whether to risk delaying my treatment by having the booster. I was diagnosed with RRMS in May 2022.
With Cladribine you can wait until after your immune system reconstitutes before having the vaccine and/or booster. You need to have dose 1 and 2 separate; the idea is to boost immunity with the 2nd and 3rd doses.
The way cladribine is licensed at present is that you don't need a maintenance treatment after dosing. However, I would love to do a trial of teriflunomide after cladribine.
I had two courses of alemtuzumab in 2013 and in 2014. On the advice of my neurologist I have had annual smears ever since but going forward now after 7 years it is going to revert back to every 3 years.
I do actually think the recommendation for annual smears was only for 4 years after the final course of alemtuzumab but would you be concerned and try and carry on having annual smears?
I I have not had any DMT since finishing alemtuzumab in 2014.
In the UK there is a staged switch happening away from cervical smears to using vaginal PCR to screen for HPV infection. In the future, this will be the norm. The good news is that it will be self-administered.
Hi yes I am aware I just wanted to know whether the initial danger of alemtuzumab activated cervical problems could still happen 7 years after treatment has finished and whether paying for a private HPV vaccination would be worthwhile I am 49 many thanks
Another option here is potentially the use of cladribine. The level of immunosuppression post-cladribine is relatively low, it does not block vaccine responses and with immune reconstitution, anti-viral or anti-HPV responses should be fine long-term.
Hi, I had CIN 3, with subsequent LLETZ, over 10 years ago. I am now 6 months post HSCT. When would you advise I get the vaccine? I've never had it and there's been no discussion about me getting it. I'm in the process of revaccinating for my other childhood vaccines. I think also I should book a smear yearly now - do you agree?
You need to speak to your haematologist. As long as you have peripheral B and T cell reconstitution the vaccine can be given. Regarding the yearly smear you need to follow the local protocol. I recall it being yearly for a few years and then if all is clear going back to the 3-yearly screening. You gynaecologist will be able to tell you the specifics. The risk of HPV-associated cancers are lower in patients who have had an IRT.
Re. the case study, some questions-
1. How long should she wait once off of ocrelizumab & starting on teriflunomide / interferon before taking the first dose of the vaccine ?
2. Can she change back to ocrelizumab 4 weeks after receiving the third dose of the vaccine?
Roughly 9-12 months since your last dose of ocrelizumab. You want some B-cell reconstitution to ensure you make an antibody response.
Really interesting to hear about this case study. Having had HPV infection and smear abnormalities in the past (CIN 1) and had recurrence with associated diathermy treatments I have luckily had clear smear tests (including a recent test showing no HPV) for a number of years. However my husband was diagnosed and successfully treated for intra-epithial penile neoplasia a while ago, suggesting that any HPV infection I might have had may be of one of the higher risk types of HPV.
However, I am now on Tysabri, but at no stage during choice of treatment options was the potential for activation of HPV discussed as a risk factor. As I might have to consider a change to another immune-suppressive DMT at some point then being aware of potential impact of previous HPV infection is worth knowing and I would certainly consider getting a polyvalent vaccine if I could.
Yes, you can have the HPV vaccine at any stage on natalizumab, which won't block your vaccine response.
Hello! Very interesting article!
I have a question about boosters.
I have had 3 ceravix vaccinations in childhood and currently have been HPV positive for 2-3 years. Do you recommend having a Gerasil-9 booster vaccination before starting my cladribine treatment and can this be given as a one off vaccination, or does it need to be administered as a series of 3 again?
This booster is said to delay starting my treatment by 4 weeks (being as a single dose of Gerasil-9). I am unsure whether to risk delaying my treatment by having the booster. I was diagnosed with RRMS in May 2022.
Any advise would be hugely appreciated!
Thank you,
Fatma
With Cladribine you can wait until after your immune system reconstitutes before having the vaccine and/or booster. You need to have dose 1 and 2 separate; the idea is to boost immunity with the 2nd and 3rd doses.
Thank you for responding once again!
If Gerasil-9 is not a live or attenuated vaccine do you think I would still need to wait 4 weeks after having it to start mavenclad?
No the lymphocyte nadir is at ~3 months after dosing. I suspect 2-3 weeks will be fine.
https://gavingiovannoni.substack.com/p/case-study-why-cladribine-is-the#details
Thank you for taking the time to respond. I hadn’t noticed this article.
So even if I’ve had 3 doses of Ceravix in childhood, would I still need to have 3 doses of Gerasil-9 or would 1 dose as a booster be enough?
Can doses 1 and 2 be given at the same time?
Thank you for your help and advice.
What DMT would could one use as a maintenance therapy post Cladribine ?
The way cladribine is licensed at present is that you don't need a maintenance treatment after dosing. However, I would love to do a trial of teriflunomide after cladribine.
I had two courses of alemtuzumab in 2013 and in 2014. On the advice of my neurologist I have had annual smears ever since but going forward now after 7 years it is going to revert back to every 3 years.
I do actually think the recommendation for annual smears was only for 4 years after the final course of alemtuzumab but would you be concerned and try and carry on having annual smears?
I I have not had any DMT since finishing alemtuzumab in 2014.
All of my smears have been clear.
Many thanks
In the UK there is a staged switch happening away from cervical smears to using vaginal PCR to screen for HPV infection. In the future, this will be the norm. The good news is that it will be self-administered.
Hi yes I am aware I just wanted to know whether the initial danger of alemtuzumab activated cervical problems could still happen 7 years after treatment has finished and whether paying for a private HPV vaccination would be worthwhile I am 49 many thanks
No your immune system has reconstituted so it should be able to deal with an HPV infection and HPV vaccine if you decided to be vaccinated.
Brilliant many thanks as always for your reply.
So many of the questions I have are raised either here or on the Bart's blog.
Another option here is potentially the use of cladribine. The level of immunosuppression post-cladribine is relatively low, it does not block vaccine responses and with immune reconstitution, anti-viral or anti-HPV responses should be fine long-term.
Hi, I had CIN 3, with subsequent LLETZ, over 10 years ago. I am now 6 months post HSCT. When would you advise I get the vaccine? I've never had it and there's been no discussion about me getting it. I'm in the process of revaccinating for my other childhood vaccines. I think also I should book a smear yearly now - do you agree?
You need to speak to your haematologist. As long as you have peripheral B and T cell reconstitution the vaccine can be given. Regarding the yearly smear you need to follow the local protocol. I recall it being yearly for a few years and then if all is clear going back to the 3-yearly screening. You gynaecologist will be able to tell you the specifics. The risk of HPV-associated cancers are lower in patients who have had an IRT.
Thank you for taking the time to reply.