NAPLEX Question of the Week: Biologics

A rapidly growing area of pharmacotherapy are biologics. It seems every month a new agent comes along that is being used for an autoimmune disease such as rheumatoid arthritis or psoriatic arthritis. This week's question focuses on biologic therapy.

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A 42 year old female with past medical history of rheumatoid arthritis (RA) is scheduled to go to Ecuador in two months. She has a significant past medical history for RA, asthma and gerd for which she takes methotrexate 15mg weekly PO,  Advair Diskus 50/250mcg 1 inhalation BID, and omeprazole 20mg daily. She makes a travel clinic appointment at the county health department to determine which vaccines she should receive. Upon questioning by her nurse, the patient reveals that she is due to begin etanercept therapy this coming week in addition to her methotrexate due to increased worsening of symptoms. The nurse determines that based on where she will be traveling in Ecuador, she should receive an annual flu vaccine as well as yellow fever vaccine as part of her overall regimen.

Which of the following is appropriate regarding administration of these vaccines?

A. It is appropriate to give both the yellow fever and FluMist Quadrivalent vaccines either before or after starting etanercept therapy.

B. It is appropriate to give the yellow fever and FluMist Quadrivalent vaccines before starting etanercept therapy.

C. It is appropriate to give the yellow fever and inactivated flu vaccine before or after starting etanercept therapy.

D. It is appropriate to give the yellow fever and inactivated flu vaccine after starting etanercept therapy.

Answer and Rationale: The correct answer is B. Live vaccines are not recommended to be given after starting biologic therapy. An example of this is etanercept, a TNF-alpha inhibitor. Therefore yellow fever should not be given while on etanercept therapy, making answers A, C, and D incorrect. The curveball in this question is the difference in flu vaccines. The FluMist is a live vaccine, making it inappropriate after starting therapy but is fine before starting therapy. While answers C and D contain the inactivated flu vaccine or "dead virus" which are fine for patients on biologics, those answers are still incorrect as the yellow fever vaccine cannot be given after starting biologic therapy.

There are a number of other considerations with biologic therapies such as reactivating TB, hepatitis B, stopping during active infection as well as many others. Definitely review this important class before taking the exam.

Christopher M. Bland

Clinical Professor, University of Georgia College of Pharmacy

Dr. Christopher M. Bland is a Clinical Professor at the University of Georgia College of Pharmacy at the Southeast GA campus in Savannah, GA. Dr. Bland has over 20 years of academic and clinical experience in a number of clinical areas. He is a Fellow of both the Infectious Diseases Society of America as well as the American College of Clinical Pharmacy. He is co-founder of the Southeastern Research Group Endeavor, SERGE-45, with over 80 practitioners across 14 states involved. Dr. Bland serves as Associate Editor for the NAPLEX Review Guide 4th edition as well as Editor-In-Chief for the Question of the Week. He has provided live, interactive reviews for more than 10 Colleges/Schools of Pharmacy over the course of his career. 


Go to the profile of Ahmed Shible
11 months ago

Hello Dr. Bland,

Doesn't methotrexate also suppress the immune system, and thus making the patient ineligible for both vaccines even before starting etanercept? or are the low doses of methotrexate used in RA not immunosuppressive like those used in chemotherapy?

Thanks so much for your strong work. I like your channel a lot and this how far back I have gone!

Go to the profile of Christopher M. Bland
11 months ago

Hi Ahmed- You are correct in that for potent immunosuppressants this would be an issue. Since these are low doses of MTX (< 20mg weekly) they are generally okay. Hope this helps and thanks for your kind words.