- What It’s Like Getting Sick When You Live With Autoimmune Disease
- Navigating the Winter with an Autoimmune Disease
- Stay Warm
- Stay Safe
- Stay Active
- Power Up Your Anti-Viral Arsenal
- Feed and Strengthen Your Body
- Work on Lowering your Immune Burden
- Get a flu shot
- Preventing autoimmune disease after a viral infection
- Q: Where is the best information available concerning vaccination recommendations for patients with autoimmune diseases?
- Q: Will the immunosuppressive drugs my patient is receiving interfere with the safety or effectiveness of flu vaccines?
- Q: What about methotrexate? Does it pose special issues?
- Q: Does the high dose influenza vaccine offer advantages for patients with immunosuppressive illnesses?
- Q: What about my patient who tells me they have an egg allergy?
- Q: Who should not get a flu shot?
- Q: What are best practices to increase flu vaccine coverage in my practice?
- Q: What should I say to a patient who told me that that last year’s flu vaccine was only 20% effective and who is not interested in getting one?
- Vaccines and Autoimmune Diseases
What It’s Like Getting Sick When You Live With Autoimmune Disease
This week it happened. I wash my hands with surgical scrub, I drink tea with tulsi in it every morning, I do all I can to try to stay away from ill people and germ incubators. It’s also hard to tell when I am coming down with something, since wide temperature swings, body aches, fatigue and digestive issues are typical for me. Heck, my baseline state of being involves flu-like symptoms. But being human and having to be out in the part of the world that requires pants and shoes means that I inevitably will catch something. A bug.
And this was no sweet-faced, rosy-cheeked ladybug waving friendly antennae, mind you. This was a slimy, ghost-white thing that slithered up into my sinuses and oozed into my lungs, filling the top third of my body with its gook, pressurizing my head and ringing my ears like church bells. My hot/cold/fussy/achy body.
It’s still taking its sweet time to move along, swinging by to “just pick up a few things” multiple times a day but not taking much with it. My cat crawls on my belly to soothe me (and steal my body heat), then stares wide-eyed in betrayal as she bounces up and down with every cough, a boat on a storm-tossed sea of blanket.
Sometimes being sick with something acute like a cold brings a little relief to my autoimmune self. It’s like my ramped-up immune system finally gets to channel its energy in a productive way for once instead of taking it out on me. My immune system is a hyper child who does amazing things when in gymnastics or track, but tears up the house most of the time outside of practice and competitions. For me, being sick with a cold or flu is that brief moment of reprieve when the house is quiet and still, before practice is over and the chaos returns.
And, oh, does it return! There must be ginseng cupcakes covered in jellybeans and sprinkled with instant coffee powder served after those practices, because once the acute illness passes, my immune system does not wanna stop. So it’s usually about a week of being acutely ill, soon followed by a flare of one or more of my diseases. A one-two punch that leaves me scrambling in week three to try to catch up on everything that fell by the wayside. (I haven’t found solid research to back up the idea that an acute illness will then flare up a chronic autoimmune illness like my psoriatic arthritis, psoriasis or Hashimoto’s, by the way. This is just the pattern I’ve noticed with myself. Though there isn’t much research out there on us autoimmune folks in general, so one day someone might find that it’s true.)
My immune system doubling down on me means that I have to double up on the self-care stuff. Not easy, I know. I make myself lie around staring at TV or flipping through magazines even when I start feeling a little antsy. Carry around water or tea at all times to keep the fluids going. Eat off paper plates or takeout containers (and say a little prayer for forgiveness from the earth as I do). Let things pile up, trying to keep a list so I’ll remember what they were once I’m feeling better. When I get the urge to jump up and take care of something, I add it to the list instead. For me, healing often includes lots and lots of solitude. It’s different for everyone, though. Each body, each person and each illness has their own preferences and needs, especially when ill. Honor that in yourself and in others.
Getty Image by MichikoDesign
Winter is coming, brace yourself. While for many this means singing carols and enjoying the holiday lights, for those living with autoimmune diseases including type 1 diabetes, rheumatoid arthritis, multiple sclerosis, and lupus, it can mean a flurry of concerns. Painful freezing temperatures, slippery ice, and dreary dark days may make you want to hide until spring. Break the ice this winter with these tips to stay cozy and warm, prepare for snowy conditions, and maintain an active lifestyle despite the chill.
Jack Frost nipping at your nose? Avoid a flare-up by bundling up!
- Many people with joint pain experience worse symptoms in the cold. Hot packs for your hands and warming shoe inserts can do wonders for sensitive fingers and toes.
- For those with rheumatoid arthritis, the Arthritis Foundation provides a free pain level predictor for the weather in your area, allowing you to plan for cold temperatures, rain, or low barometric pressure.
- It is important to make sure your medicine and devices stay warm and usable if you live with type 1 diabetes. Carry your device inside your clothes to keep your meter at a safe temperature, and bring back-up insulin in case your insulin freezes.
- The best way to bundle up and keep out the chill is by stacking lots of layers. Excess heat can be a trigger for multiple sclerosis and other autoimmune diseases, which makes loose layers perfect for regulating temperature as needed.
The best defense is a good offense, so prepare early for any safety concerns caused by icy conditions.
- Colder temperatures can affect blood sugar in unpredictable ways, so test often if you have type 1 diabetes in case of an unexpected spike or low.
- To prevent skin irritation remember to wear sunblock even on cloudy days and wrap up with a scarf, especially if you live with lupus.
- Ensure that any mobility devices you use–such as a walker or wheelchair–are outfitted for ice, snow, and sleet to prevent a painful fall.
- Those living with autoimmune disease are more at risk for seasonal colds or cases of the flu. Flu shots are a great form of prevention, but avoid nasal sprays that have a live form of the virus.
- If depression is a symptom of your autoimmune disease, seasonal affective disorder may intensify those symptoms. Consider light therapy or vitamin D supplements to ease the effects.
Get outside the house and start moving to beat the winter blues and reduce your aches and pains.
- Try a low-impact winter sport, like cross-country skiing or snowshoeing, if traditional winter activities are too hard on your joints.
- Don’t miss out on traditions with family and friends. Call ahead to ask which local ice skating rinks and hiking trails in your community are wheelchair accessible.
- Always warm up and cool down when working out to loosen your muscles and joints. Plan a rest period before you get tired to prevent exhaustion or injury.
- Stay out of the cold with indoor exercises, such as a dance, barre, or spin class.
- You can stay active during the winter without even realizing it. Shoveling snow for 10 minutes, gift shopping for 20 minutes, or putting up holiday lights for 30 minutes all burn 100 calories.
If winter has you feeling snowed under, use these tips to make the most of the season!
The information provided in this post should not be taken as a substitute for professional medical advice. Always check in with your doctor to make sure you’re following the right precautions and planning according to your health needs.
It’s finally fall. And while fall brings many wonderful things such as crisp evenings, beautiful foliage and pumpkin spice lattes it also brings with it the flu. Most cases of the flu and common cold are relatively benign for most people, but for those with autoimmune diseases viral infections can mean symptom flares for their autoimmune condition. Therefore it is important for those with autoimmune diseases to do their best to prevent viral infections like the flu and the common cold from aggravating their symptoms.
Viruses like the influenza (flu) and rhinovirus (common cold) tend to aggravate autoimmune diseases because they cause the immune system to flare in response to the virus. Symptoms like coughing, sneezing, sore throat, chills and fever are all symptoms of your immune system acting to fight the virus. And while it is important for your immune system to fight off those viruses, if it is already overactive because of autoimmunity, then it can make those symptoms worse.
But fortunately for those of you with autoimmune diseases, there are several ways you can help prepare yourself to not only reduce your changes of getting a viral infection, but also to reduce your chances of having an autoimmune flare. Here are some of those ways:
Power Up Your Anti-Viral Arsenal
Going into cold and flu season, there are many different herbs and supplements that can help you prevent viruses from getting out of hand. The best and most readily available supplements include vitamins and minerals such as Vitamin C and Zinc. B vitamins can also help promote healthy immune system function. Herbal therapies such as echinacea, andrographis, and elderberry can also help to prevent viral infections. Make sure you talk with your healthcare provider about the appropriate dosages for these therapies.
Feed and Strengthen Your Body
Exercise and healthy eating habits can do wonders for helping you fend off viruses. Mild to moderate aerobic exercise 3-4x a week can help not only improve immune function, but can help prevent cold and flu. Promoting a diet full of vitamin and mineral rich fruits and vegetables can also help your body stock up on the nutrients is needs to fight infection. You can find additional tips on ways to prevent colds and flu here.
Work on Lowering your Immune Burden
Many autoimmune diseases flare up because the immune system becomes so overstimulated by multiple triggers that it begins to produce symptoms. By finding and controlling triggers such as food allergies, hormonal imbalances, GI imbalances or heavy metal toxicities, the body’s immune burden decreases making it more tolerable to triggers such as viruses. When the immune burden decreases, viral infections may not be enough of a trigger to produce symptoms, creating a more tolerable experience.
Get a flu shot
While a flu shot is not protective against all forms of the influenza virus, it can help prevent against some of the most common strains. Those with serious life threatening autoimmune diseases, or those at high risk for flu complications, should consider getting a flu shot. If you are uncertain as to whether you should get a flu shot this year, contact your doctor as they can explain to you the risks and benefits of receiving a flu shot this year.
While getting the flu or the common cold is never pleasant, it shouldn’t lead you feeling worse because of autoimmune flares. If you have further questions about how to prevent colds and flus from affecting your autoimmune disease, call our office today at 206-588-1227 and schedule an appointment with one of our expert physicians.
But as the body throws its effort into making ever-better antibodies during an infection, the random mutations that create those ever-stronger antibodies may also produce antibody-producing B cells that attack one’s own body, mistakenly triggering autoimmune diseases like rheumatoid arthritis, systemic lupus erythematosus or multiple sclerosis.
André Ballesteros-Tato, Ph.D., assistant professor, University of Alabama at Birmingham Department of Medicine, likens those mistaken autoimmune attacks to the collateral damage that can happen in a wartime battle.
In research published in Nature Immunology, Ballesteros-Tato and colleagues used mice to study regulatory mechanisms in the immune system that prevent autoimmune disease. Using an influenza infection model in mice, they have found that a particular population of immune cells developed during the later stages of the immune response to the influenza infection. These cells, called T follicular regulatory cells, or TFR cells, subsequently prevented the generation of self-reactive antibody responses. At the same time, they did not affect the influenza-specific immune reaction.
“This research gives us clues of what to look for when we look at how autoimmune disease develops,” Ballesteros-Tato said.
TFR cells are poorly understood compared with the more common T regulatory, or Treg, cells, which act to shut down or suppress immunity at the end of an immune reaction. The UAB team found that the two types behaved differently during influenza infections of mice.
As is well-known, the signaling molecule interleukin 2, or IL-2, has elevated levels as the immune response begins, and IL-2 stimulates the development of the conventional Treg cells. In the mice, these cells reached their peak one week after infection. In contrast, the UAB researchers found that IL-2 signaling inhibited, rather than promoted, the development of TFR cells during the peak of the immune response in mice. This inhibition used a mechanism that depended on the Blimp1 transcriptional repressor. Blimp1 prevented expression of the Bcl-6 master transcription factor, precluding TFR cell development.
When the influenza virus was eliminated and IL-2 levels were falling, some Treg cells downregulated the expression of CD25, which is part of the IL-2 receptor on the surface of Treg cells. Those cells upregulated the Bcl-6 master transcription factor and differentiated into TFR cells, reaching their peak numbers 30 days after infection. The TFR cells migrated to follicles of the lymph nodes, where antibody-producing B cells are known to proliferate and mutate their antibody genes to create ever-stronger antibodies.
In the follicles, the TFR cells prevented the accumulation of B cell variants that had mistakenly mutated to make antibodies that could attack the body’s own cells. The TFR cells did not reduce the immune response against the influenza virus. Experimental methods that removed the TFR cells or prevented their development allowed expansion of B cells that made anti-self antibodies, as measured by anti-nuclear antibodies.
“In summary,” Ballesteros-Tato and colleagues wrote in the paper, “our data demonstrate that IL-2 signaling temporarily inhibits TFR cell responses during influenza infection. However, once the immune response is resolved, TFR cells differentiate and migrate to B cell follicles, where they are required for maintaining B cell tolerance after infection. Thus, the same mechanism that promotes conventional Treg cell responses, namely IL-2 signaling, also prevents TFR cell formation.
By Cassandra M. Calabrese, DO (@CCalabreseDO) and Leonard H. Calabrese, DO (@LCalabreseDO)
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We are now well into the 2019-2020 flu season. For patients with autoimmune diseases (such as rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease and psoriasis) — particularly for those on immunosuppressive therapies — the stakes are high. While flu infects tens of millions of individuals, causes over a half a million hospitalizations and can lead to death in 30,000-60,000 Americans in the general population, the disease carries even greater morbidity in our autoimmune population. Thus, maximizing vaccination coverage is a vital part of overall care.
The following Q&A provides some practical advice from Cleveland Clinic’s Rheumatology-Infectious Disease Clinic for practicing physicians.
Q: Where is the best information available concerning vaccination recommendations for patients with autoimmune diseases?
A: While most professional organizations make some broad recommendations regarding vaccines, in patients with specific diseases, the Centers for Disease Control and Prevention is the standard bearer of such information. (Recommendations for patients with autoimmune disease can be found in Table 2, under “immunocompromised” ). These recommendations emphasize the importance of vaccinating this population because of greater morbidity and mortality from influenza. The recommendation is simple: one dose of either quadrivalent inactivated vaccine or high-dose trivalent vaccine for those over 65 years of age. Remember, the annual flu vaccine is recommended for ALL patients in your practice.
Q: Will the immunosuppressive drugs my patient is receiving interfere with the safety or effectiveness of flu vaccines?
A: This is complex question given the multitude of immunosuppressive and targeted therapies we have available. In general, for patients who are not receiving high level immunosuppression, the most commonly used drugs and biologics have no clinically significant effect on vaccine response and therefore pose no practical issue. A major exception is rituximab and other B cell depleting drugs, which profoundly affect vaccine responses; thus, if possible, timing should be adjusted to the nadir of drug administration. Furthermore, since influenza vaccines are killed (i.e., except the live nasal vaccine, which is contraindicated in this population), immunosuppressive therapies pose no additional safety issue.
Q: What about methotrexate? Does it pose special issues?
A: Indeed, among the immunosuppressive drugs widely used to treat autoimmune disease, methotrexate has demonstrated the most consistent capacity to reduce the immunogenicity of a number of vaccines, including influenza. A series of recent studies from a South Korean group has demonstrated that merely withholding two doses of methotrexate following influenza vaccine can boost immune response by nearly 50% with no apparent adverse effects on disease control. While withholding methotrexate in such fashion is not formally recommended by any professional body, it is our practice to do so when at all possible.
Q: Does the high dose influenza vaccine offer advantages for patients with immunosuppressive illnesses?
A: The high dose vaccine (Fluzone High-Dose vaccine) contains approximately four times the antigenic load of virus compared with the standard vaccine and, in healthy individuals > 65 years of age, appears to be more immunogenic and possibly more clinically effective. Unfortunately, for the 2019-2020 flu season, the high-dose vaccine is only available as a trivalent vaccine with two A strains and only a single B strain (a quadrivalent form was recently approved and should be available for the next flu season). Limited studies in rheumatoid arthritis have suggested that the high dose form results in higher antibody titers in all patients regardless of age, which is encouraging. We think this is something to watch but have concerns, as early epidemiologic reporting in the current flu season indicates that B strain infections are predominant in the U.S., which is unusual for this time of year. When these data can be duplicated with the quad form of the high dose vaccine next year, we believe our enthusiasm will increase considerably for this strategy. Be aware, however, that the high dose vaccine is nearly twice as expensive as the standard dose and private insurance is unlikely to cover it for those < 65 years of age.
Q: What about my patient who tells me they have an egg allergy?
A: Egg allergy is NOT a contraindication to receiving any formulation of seasonal influenza vaccine, including egg-based vaccines. This has been the recommendation since the 2016-2017 Advisory Committee on Immunization Practices (ACIP) update to influenza vaccine guidelines. Even patients with a history of severe egg allergies (e.g., respiratory distress, cardiovascular or GI symptoms) can receive any influenza vaccine under the supervision of a healthcare provider who can recognize and manage severe allergic conditions.
Q: Who should not get a flu shot?
A: The only true contraindication to receiving the flu shot is if a patient has experienced a severe (life threatening) allergy to a prior dose of a seasonal influenza vaccine, or in a patient with a severe allergy to a component of the vaccine. A history of Guillain-Barré after a flu shot or any other vaccine is also a contraindication, in our opinion.
Q: What are best practices to increase flu vaccine coverage in my practice?
A: There exist numerous barriers to vaccine administration in patients with autoimmune disease, including decreased awareness by both practitioners and patients, vaccine hesitancy, communication issues between specialties, confusing vaccine series (e.g., pneumococcal), insurance issues or limited stock of the vaccine. Unfortunately, vaccine uptake remains very low in practices treating patients with immune-mediated diseases. A combination of interventions will likely be needed to increase uptake, including systematic interventions directed at both patients and providers (e.g., standing orders, sending reminders in the mail, placing posters in clinic, keeping adequate stock of flu vaccine). Studies have shown that strong physician/provider recommendations have a significant impact on vaccine uptake. We also like to remind our patients that even if they are reluctant to be vaccinated for personal reasons, they should still strongly consider the vaccination in order to protect their friends and loved ones who may be vulnerable. To help this cause, try to carve out a few minutes during each patient visit this flu season to address the seasonal influenza vaccine. For patients who are not interested, try to understand their health beliefs and educate them on the importance of this yearly vaccine.
Q: What should I say to a patient who told me that that last year’s flu vaccine was only 20% effective and who is not interested in getting one?
A: Influenza vaccine efficacy varies from year to year. Studies have shown that even relatively low-efficacy influenza vaccines can have a significant impact on infection prevention within the general population.
Flu season is here to stay. Flu season usually peaks in January and February, but can last as late as May. While it is best to vaccinate in September or early October, it’s never too late to vaccinate.
Vaccines and Autoimmune Diseases
Autoimmune diseases occur when the body reacts against itself. Some diseases characterized by this type of reaction include Guillain-Barre Syndrome (GBS), multiple sclerosis, and diabetes. Autoimmunity can be induced by genetic predispositions. But, sometimes bacterial or viral infections can cause autoimmune diseases. For example, campylobacter, an intestinal bacterial infection, can cause GBS, a disease of the peripheral nervous system. Influenza virus can exacerbate symptoms of multiple sclerosis, a disease of the central nervous system. And Coxsackie virus can cause diabetes, a disease that occurs when the body reacts against cells in the pancreas that make insulin. Because natural infections can lead to autoimmune conditions, people can reasonably wonder whether vaccines can also cause autoimmunity as well.
Numerous studies have examined many different vaccines. To date, none have consistently been shown to cause autoimmune diseases. In some studies influenza vaccine was shown to cause GBS at a rate of one case per million vaccine recipients. But, this should be viewed in light of the fact that natural influenza infection causes GBS in 17 per million people infected. So, in a sense, influenza vaccine could be viewed as preventing a more common cause of GBS.
The notion that vaccines don’t cause autoimmunity makes sense. Since vaccines don’t drive the immune response nearly as vigorously as natural infections do, it is less likely that they would induce autoimmunity. However, scientists continue to study questions related to vaccines as a cause of autoimmunity as they arise.
The following autoimmune diseases are addressed in more detail on dedicated pages:
- Multiple sclerosis
- Guillain-Barré syndrome
- Autoimmune/inflammatory syndrome induced by adjuvants (ASIA)