Background/Purpose: Patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are at high risk for serious infection, including those caused by Streptococcus pneumoniae. Administration of 23-valent polysaccharide pneumococcal vaccination (23-PPV) is recommended for patients with several co-morbidities and age >65 years. EULAR recommends 23-PPV for all patients with autoimmune inflammatory rheumatic diseases and the ACR recommends it for all patients with RA. Small observational studies suggest that administration of 23-PPV in RA patients is inadequate while none studied SLE. The purpose of our study is to determine rates and predictors of 23-PPV administration in US RA and SLE patients.

Methods: We surveyed patients across the US with RA, SLE, or osteoarthritis (OA) every 6 months from 2007 through 2011 about 23-PPV along with their demographic and health status. We identified characteristics within each diagnosis that predicted administration of 23-PPV in a subsequent 6-month period through the use of univariate logistic regression adjusted for sex and age > 65 years.  Significant predictors were combined in a multivariate logistic regression model and eliminated with backward stepwise selection until all remaining predictors were significant for an alpha of 0.05.  We also selected a subset of cases who had never received 23-PPV at baseline and used univariate Cox proportional hazards models controlling for diagnosis group to predict the timing of the first administration of 23-PPV.  Significant predictors were combined in a multivariate Cox proportional hazards model and eliminated with backward stepwise selection until all remaining predictors were significant for an alpha of 0.05.

Results:  A total of 15,954 patients participated in the study (11,952 RA, 1,773 SLE, and 2,229 OA). Among these groups 69.8%, 65.2%, and 67.8% of patients reported having ever received 23-PPV, respectively.  SLE patients who reported receiving 23-PPV in the subsequent 6 months were more likely to be over 65 (OR 1.64, p=0.01), taking prednisone (OR 1.38, p=0.01), and to have chronic lung disease (OR 1.68, p<0.01).   RA patients age > 65 (OR 1.70, p<0.01), male (OR 1.16, p=0.01), on biologic therapy (OR 1.18, p=0.03) or prednisone (OR 1.20, p<0.01), and suffering from chronic lung (OR 1.53, p<0.01) or heart disease (OR 1.20, p=0.03) were more likely to receive 23-PPV.  Age > 65 was the strongest predictor of 23-PPV use in OA patients (OR 2.06, p<0.01). Patients were more likely to receive their first 23-PPV if they were over 65 (HR=2.05, p<0.01), male (HR=1.2, p=0.01), taking a non-biological DMARD (HR=1.32, p<0.01), taking a biological DMARD (HR=1.31, p<0.01), had chronic lung disease (HR=1.33, p<0.01), or had a lower SF36 PCS score (HR=0.99, p<0.01).

Conclusion: Despite current EULAR and ACR recommendations nearly a third of RA and SLE patients have never received a pneumococcal vaccination in a large, contemporary US cohort. Age greater than 65 years and chronic lung disease were the strongest predictors of 23-PPV administration. This is the first study to report that use of immunosuppressive drugs other than prednisone was not associated with pneumococcal vaccination in SLE patients.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/predictors-of-pneumococcal-vaccination-in-patients-with-rheumatoid-arthritis-and-systemic-lupus-erythematosus/