BartsMS #MSCOVID19 #vaccination advice: The update of the update of the…

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So, six weeks ago we said this:

However, in the COVID19 era, the life cycle of evidence emerging, and us reflecting on it, has shrunk. Hence, another update on our vaccine advice was overdue:

COVID-vaccines-DMT_BartsMS-guidance_March-update_final

There are two changes to the previous version:

Firstly, we’ve adapted our advice about vaccination in the context of cladribine by removing the “3 month-rule”, i.e. the advice that after a treatment cycle, one should wait for at least 3 months before undergoing vaccination. This was based on the theoretical concept that B & T cell depletion induced by the treatment would alter people’s immune responses such that they become unable to mount an effective response if given the vaccine earlier. However, no convincing evidence supporting this claim has emerged, and what’s more data from an, admittedly limited, sample of n=15 pwMS treated with cladribine and receiving vaccinations against Influenza and Herpes zoster at various time points prior to and after treatment did not reveal any relationship between the time point of vaccination, the degree of lymphocyte depletion, and effective antibody titres. @profb reported on the results of the study a little while back:

Secondly, to reduce any aches and pains associated with the vaccination, we added some simple advice regarding paracetamol (generally, 1g for adults) to be taken after the vaccination, and regularly (up to four times/day) for 48 hours, unless you are unable to take paracetamol for other health related reasons. Ibuprofen 400mg at the same dosing intervals as above would be an alternative.

Do I think this was our last word on #SARS-CoV2 #vaccination? – Highly unlikely, and I’m very pleased to report BartsMS have made significant headway with their vaccination programme. Over 570 pwMS have now been contacted, and 450 have had at least their first dose. If you are one of them, please remember to fill in your questionnaire so we can learn and share (anonymously, of course) your experience of the SARS-CoV2 vaccination; this could prove really valuable for our colleagues and your fellow MSers in the rest of the World, where vaccine experience & confidence are lower, particularly with the AstraZeneca vaccine, which is what most pwMS in our service receive. If you have lost your questionnaire, you can download it here; just send it back to the email provided:

COVID19-patient-questionnaire

We also remain keen on your blood… So, if you are as eager as we are to find out what the impact of DMTs on SARS-CoV2 vaccine antibody responses is, ping us an email on mscovid19ab@qmul.ac.uk and the team will send you some collection cards & return envelope. Whenever and wherever you had your vaccine (with your GP, at a vaccination centre, or through BartsMS), you can participate as long as you have a patient record at Barts Health NHS Trust.

Thank you!

@KlausSchmierer

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12 comments

    • For people in the UK, Rest of Europe, USA have the A/Z vaccine if offered as it will give you some protection.

      For people not familiar B.1.351 is also known as the South African variant, in the study you mention people getting the AZ did not appear to mount sufficient immune response to stop people developing symptomatic COVID-19. However, no-one in the trial got severe problems. However the people in the study tended to be young and so were unlikely to be severely affected.

      We know that you need more antibody to limit the South African variant, and likely to be the same for the Brazilian variant (P1), this is true for the other vaccines too, but in this trial in South Africa obviously not enough was made to stop infection.

      However, in the UK (i) the South African variant is not a major strain at present, so unlikely to be an issue at the moment (ii) The longer dose interval being used, will increase the level of antibody compared to that used in the trial in South Africa, although for people with immunosuppression a short duration is being recommended (iii) The T cell response is protective and data suggests that the T cell response in not directed to areas relevant for the UK, SouthAfrican and Brazilian variant. All vaccines make a T cell response. (iv) We may need to boost vaccines to deal with variants abit like the flu vaccine.

      • Thank you MD, always helpful and informative – still wish to ask if I have the option to choose, would I be better off with Pfizer, Moderna vaccines than A/Z vaccine?

        • The data changes all the time and all the vaccines will be based on the sequence data for the spike protein announced in January 2020.

        • Someone asked that of a friend…..and some said J & J you only need one Jab. Time will tell…I had my favourites but I didnt get it

  • Hi
    As a pharmacist, I would strongly caution you to dial back your recommendation of 1 g of paracetamol up to four times daily. This dose is the absolute ceiling for people with a healthy liver. Considering that some DMT’s can have an impact on the liver, this dose may be too aggressive for many pwMS. A couple of tidbits to ponder:
    Acetaminophen (paracetamol) 1,000 mg is NOT more effective than acetaminophen 500 mg.1
    In chronic liver impairment, limit the total daily dose (of paracetamol) to 2 to 3 grams (instead of the usual 4 gram max adult daily dose).2,3

    Sincerely,
    Michael
    1. Bandolier. The Oxford League table of analgesic efficacy. http://www.bandolier.org.uk/booth/painpag/Acutrev/Analgesics/lftab.html. (Accessed December 8, 2019).
    2. Lewis JH, Stine JG. Review article: prescribing medications in patients with cirrhosis-a practical guide. Aliment Pharmacol Ther 2013;37:1132-56.
    3. FDA drug safety communication: Prescription acetaminophen products to be limited to 325 mg per dosage unit; boxed warning will highlight potential for severe liver failure. January 13, 2011. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-prescription-acetaminophen-products-be-limited-325-mg-dosage-unit. (Accessed November 27, 2019).

    • Dear Michael,

      As the pharmacist working with Barts MS,
      I understand your concerns re paracetamol in patients with liver issues, but we are hoping these patients have been advised this already by members of their health care team. The issue we are trying to prevent with the “prophylactic” paracetamol is the vaccination causing fever which can be worse on the second dose of the covid-19 vaccination (Moderna, Pfizer and AstraZeneca). Some non-MS health care professionals have found taking paracetamol for a limited time has helped control this fever.

      But all patients taking paracetamol or ibuprofen for symptom control (or prophylaxis) should ensure they are able to tolerate the medication and it is not contra-indicated for them.

      Whilst the FDA has limited the dosage unit of paracetamol to 325mg – but this is not the case outside the USA, and in the UK dosage units contain 500mg of paracetamol. Caution should always be taken with the chronic (long term use) of any pain killers and should be discussed with a health care professional (Dr, Pharmacist or specialist nurse).

      The evidence re 1g dose compared to 500mg – seems to be found for both sides of the argument with https://www.ncbi.nlm.nih.gov/books/NBK373471/ recommending the dose of 1g being more effective in pain control in other (non-dental) surgery – with no evidence found for treatment of fever

      Thanks

      Joela
      Neuropharmacist

  • Dear Prof. K.

    I had my first Pfizer jab at week 34 after my last Ocrelizumab infusion.

    At week 38 my cd20 cells were 0.054 and I had my second jab of Pfizer.

    At week 41 after my last infusion of Ocrelizumab, I got my new dose of Ocrelizumab.

    Based on everything I’ve read on this blog the last few months, is it fair to assume that my possible antibody respons on Pfizer, is about the maximum one could hope for?

    Thanks and please keep doing what you are doing for us.

    Regards
    Rogier

    • Agree Rogier, in the context of how ocrelizumab is currently being used, i.e. regularly administered every 24 weeks, you’ve optimised your individual treatment towards best immunisation response choosing a significantly longer delay to your next infusion, and receiving the jabs shortly prior. Pending further revelations about T-cell responses and clinical indices (infection of vaccinated pwMS treated with DMTs), we simply don’t yet know the optimum timing.

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