Table 2

DMT and vaccination recommendations for live/non-live/gene-based vaccines as well as the recommended time of administration and expected immune response

DMT	Live vaccines^{178,s180–s183}	Non-live vaccine	Gene-based vaccine ^s89,s182		Timing of vaccine after DMT is stopped*	Timing of vaccine after DMT†	Timing of DMT after vaccine‡^s183	Immune response§
DMT	Live vaccines^{178,s180–s183}	Non-live vaccine	mRNA	Vector	Timing of vaccine after DMT is stopped*	Timing of vaccine after DMT†	Timing of DMT after vaccine‡^s183	Immune response§
HDMP	Contraindicated	Yes	Yes	Yes¶	≥1 month^s184	Therapy stopped**	≥2–4 weeks‡	May be reduced^s185
Interferon	Strict indication	Yes	Yes	Yes¶	Anytime^s186	Anytime	≥2–4 weeks‡	Similar^s187
Glatiramer acetate	Strict indication	Yes	Yes	Yes¶	Anytime^s186	Anytime	≥2–4 weeks‡	Similar^s188
Dimethyl fumarate	Strict indication	Yes	Yes	Yes¶	Not specified	Anytime	≥2–4 weeks‡	Similar^s189
Teriflunomide	Contraindicated	Yes	Yes	Yes¶	≥6 months^s190††	Anytime	≥2–4 weeks‡	Slightly reduced ^s191,s192
S1P modulators‡‡	Contraindicated	Yes	Yes	Yes¶	≥2 months^s193	Anytime	≥2–4 weeks‡	Reduced^s194–s196
Natalizumab	Contraindicated	Yes	Yes	Yes¶	≥3 months^s186	Anytime	≥2–4 weeks‡	Similar^s197,s198
B cell-depleting agents§§	Contraindicated	Yes	Yes	Yes¶	Specified¶¶	≥3–6 months***	≥2–4 weeks‡	Reduced^{s196,s199,s200}
Alemtuzumab	Contraindicated	Yes	Yes	Yes¶	Not specifieds178,s201	≥3–6 months***	≥2–4 weeks‡	Reduced^s202
Cladribine	Contraindicated	Yes	Yes	Yes¶	Specified†††	Specified‡‡‡	≥2–4 weeks‡	Similar^s196,s203
Mitoxantrone	Contraindicated	Yes	Yes	Yes¶	≥3 months^s204	Not specified	≥2–4 weeks‡	May be reduced^s178,s204

*Recommended timing of vaccination for live/attenuated vaccines after stopping DMT, with timing meant to avoid the risk of infection from the vaccine itself in immunocompromised individuals.
†Recommended timing of vaccination for non-live/gene-based vaccines with already established DMT (concerning cyclical therapies after last administration of DMT) to generate the most protective vaccine response possible.
‡Recommended timing of the start of a DMT/next dose of a DMT (especially concerning cyclical therapies) after completion of the vaccine to enable a protective vaccine response before the immune response is possibly affected by the DMT/next dose of DMT—at least 2 weeks for non-live/gene-based vaccines and at least 4 weeks for live/attenuated vaccines (here also for safety reasons).
§Data only for non-live vaccines available.
¶II Non-replicating viral vector vaccines.
**III After end of therapy or after dose reduction of prednisone equivalent <20 mg/day in adults.^s184
††IV Washout option with active carbon or cholestyramine, regardless of the washout procedure chosen, a subsequent check of the plasma level by two separate tests at least 14 days apart, and a waiting period of 1.5 months between the first measurement of a plasma level below 0.02 mg/L and the live vaccination is required.^s190
‡‡a Sphingosine-1-phosphate (S1P) receptor modulators including fingolimod, siponimod, ozanimod and ponesimod.
§§b Including rituximab, ocrelizumab and ofatumumab.
¶¶V At least 6 months for revaccination and 12 months for primary vaccination, if possible^s184 respectively until B cell recovery.^s178
***VI At least 3–6 months apart depending on regional recommendations.^{s94,s205–s207}
†††VII Until white cell counts are within normal limits.^s208
‡‡‡VIII Available limited data do not suggest that timing the vaccine in relation to your cladribine dosing is likely to make a significant difference in vaccine response.^{s94,s196,s203}
DMT, disease-modifying therapy; HDMP, high-dose methylprednisolone; mRNA, messenger RNA.