12 Immunization and Immunomodulating Medications

Vaccine purposes and products

Vaccines stimulate active immunity against infectious disease. Generic vaccine names usually identify the disease or antigen, while brand names identify particular products. The right vaccine and schedule depend on age, health conditions, prior doses, and current guidance; product availability and recommendations can change. The products below are common U.S. examples, not a dosing schedule.

Common vaccine examples

Common products and distinctions include:

• COVID-19: Comirnaty, Spikevax, and Nuvaxovid prevent COVID-19. Products use different technologies, including mRNA and protein subunit.

• Influenza: Fluzone and Flublok are injectable, non-live examples. FluMist is a live attenuated intranasal vaccine. These vaccines prevent seasonal influenza.

• Tetanus, diphtheria, and pertussis: Boostrix and Adacel are Tdap vaccines. Td products such as Tenivac cover tetanus and diphtheria.

• Hepatitis A and B: Havrix and Vaqta prevent hepatitis A. Engerix-B, Recombivax HB, and Heplisav-B prevent hepatitis B; Heplisav-B is an adjuvanted recombinant vaccine. Twinrix combines hepatitis A and B vaccines.

• Human papillomavirus (HPV): Gardasil 9 prevents infection from HPV types associated with several cancers and genital warts.

• Zoster: Shingrix is a recombinant, non-live vaccine that prevents shingles and related complications. It differs from the older live zoster vaccine.

• Pneumococcal disease: Prevnar 20, Capvaxive, and Pneumovax 23 are examples. Product choice depends on vaccination history and current recommendations.

• Measles, mumps, and rubella (MMR): M-M-R II and Priorix prevent these diseases; both are live attenuated vaccines.

• Varicella: Varivax prevents chickenpox and is live attenuated.

• Respiratory syncytial virus (RSV): Abrysvo, Arexvy, and mResvia prevent RSV lower respiratory tract disease in eligible groups. Products and recommendations differ by age and circumstance.

• Meningococcal disease: Menveo and MenQuadfi are MenACWY products that protect against serogroups A, C, W, and Y. Bexsero and Trumenba are MenB products that protect against serogroup B.

Consult current CDC recommendations for who should receive each vaccine.

Conventional immunomodulating medicines

Immunomodulating medicines reduce or redirect immune activity to control inflammation, prevent organ rejection, or treat autoimmune disease. Conventional disease-modifying antirheumatic drugs (DMARDs) and targeted therapies can reduce disease activity and tissue damage; unlike analgesics, many are intended to modify the disease process.

• Methotrexate (Trexall; Otrexup): An antimetabolite and conventional DMARD for rheumatoid arthritis (RA), psoriasis, and other inflammatory conditions. For inflammatory disease it is usually taken once weekly, not daily. It can cause bone-marrow, liver, lung, and fetal toxicity.

• Hydroxychloroquine (Plaquenil): An antimalarial and conventional DMARD used for systemic lupus erythematosus (SLE) and RA. Long-term use can damage the retina, so eye monitoring is important.

• Sulfasalazine (Azulfidine): A conventional DMARD and anti-inflammatory used for RA and inflammatory bowel disease (IBD), including ulcerative colitis.

• Leflunomide (Arava): A pyrimidine-synthesis inhibitor and conventional DMARD used for RA and psoriatic arthritis. Important concerns include liver toxicity and fetal harm.

• Prednisone (Rayos; generic products): A glucocorticoid that rapidly reduces inflammation in flares and many autoimmune conditions. Long-term use can cause infection risk, osteoporosis, hyperglycemia, and adrenal suppression.

• Azathioprine (Imuran; Azasan): A purine antimetabolite used in selected autoimmune disorders and transplant regimens. It can suppress bone marrow; metabolism-related testing and blood-count monitoring may be needed.

• Mycophenolate mofetil (CellCept): An antimetabolite immunosuppressant used to prevent rejection after kidney, heart, or liver transplantation and for some autoimmune diseases. Major concerns include serious infection and embryo-fetal toxicity.

• Cyclosporine (Neoral; Gengraf): A calcineurin inhibitor used to prevent transplant rejection and for selected inflammatory disorders. Monitor for kidney toxicity, hypertension, and interactions.

• Tacrolimus (Prograf): A calcineurin inhibitor commonly used as a transplant immunosuppressant and also used topically for some inflammatory skin disease. Monitor for kidney toxicity, tremor, and interactions.

Biologics and targeted therapies

Biologics are engineered proteins, often monoclonal antibodies or fusion proteins, that target particular immune signals or cells. Biosimilars may have different brand names but are highly similar to a reference biologic.

• Tumor necrosis factor (TNF) inhibitors: Adalimumab (Humira), infliximab (Remicade), etanercept (Enbrel), certolizumab (Cimzia), and golimumab (Simponi) are used for RA, psoriatic arthritis, ankylosing spondylitis, and other conditions depending on the agent. Some treat Crohn disease or ulcerative colitis, but etanercept is not an IBD treatment. Serious infection, including tuberculosis reactivation, is an important risk.

• Interleukin-6 (IL-6) receptor inhibitors: Tocilizumab (Actemra) and sarilumab (Kevzara) are used for RA and other selected inflammatory conditions. Tocilizumab is also used for giant cell arteritis.

• Interleukin-1 (IL-1) receptor antagonist: Anakinra (Kineret) is used for RA and selected autoinflammatory conditions.

• T-cell costimulation modulator: Abatacept (Orencia) is used for RA, psoriatic arthritis, and juvenile idiopathic arthritis.

• B-cell-depleting anti-CD20 antibody: Rituximab (Rituxan) is used for RA and selected autoimmune diseases, including some vasculitides. It can reduce vaccine response.

• Interleukin-17 inhibitor: Secukinumab (Cosentyx) is used for plaque psoriasis, psoriatic arthritis, and axial spondyloarthritis.

• Interleukin-12/23 inhibitor: Ustekinumab (Stelara) is used for plaque psoriasis, psoriatic arthritis, Crohn disease, and ulcerative colitis.

• Gut-selective integrin inhibitor: Vedolizumab (Entyvio) is used for Crohn disease and ulcerative colitis and acts primarily in the gut.

• Janus kinase (JAK) inhibitors: Tofacitinib (Xeljanz), upadacitinib (Rinvoq), and baricitinib (Olumiant) are oral targeted therapies for selected inflammatory diseases, including RA. Indications differ by drug. FDA warnings include serious infections and increased risks of major cardiovascular events, malignancy, thrombosis, and death for certain agents and patient groups.

Vaccination during immunosuppression

Live attenuated vaccines require special caution because the vaccine organism can replicate. MMR, varicella, and intranasal live influenza vaccine are examples. Live vaccines are generally avoided in people with severe immunosuppression, but the decision depends on the specific treatment and degree of immune suppression.

Non-live vaccines do not replicate and can generally be administered safely to immunocompromised people, although their immune response may be weaker. Examples include injectable inactivated influenza vaccine, recombinant zoster vaccine (Shingrix), and many pneumococcal vaccines.

When feasible, review and update vaccines before starting substantial immunosuppressive treatment. Timing around therapy, especially anti-B-cell treatment such as rituximab, needs individualized clinical guidance. Do not stop or delay prescribed therapy without the treating clinician’s advice. Before many biologic or targeted therapies, clinicians assess for latent tuberculosis and relevant infections such as hepatitis B. During therapy, monitor for infection and drug-specific toxicities.

High-yield distinctions

Several medication associations summarize the main safety distinctions:

• Methotrexate: A conventional DMARD, typically taken weekly for inflammatory disease; monitor for marrow, liver, lung, and fetal toxicity.

• Humira, Remicade, and Enbrel: TNF inhibitors; screen for tuberculosis and watch for serious infection. Etanercept (Enbrel) is not used for IBD.

• CellCept: Mycophenolate mofetil, used as a transplant immunosuppressant; notable risks include fetal toxicity and infection.

• Rituxan: An anti-CD20 B-cell-depleting antibody that can blunt vaccine responses.

• Xeljanz, Rinvoq, and Olumiant: Oral JAK inhibitors with FDA class safety warnings.

• Shingrix: A recombinant, non-live shingles vaccine; MMR and Varivax are live vaccines.

Immunization medications prevent infection, while immunomodulating drugs treat autoimmune inflammation or prevent transplant rejection. For people receiving immunosuppression, vaccine type and timing matter: live vaccines may be unsafe, while non-live vaccines are generally safer but may produce a weaker response. Patient-specific decisions should use current CDC recommendations and FDA labeling.

• Live attenuated vaccine