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

DMTLive vaccines178,s180–s183 Non-live vaccineGene-based vaccine s89,s182 Timing of vaccine after DMT is stopped*Timing of vaccine after DMT†Timing of DMT after vaccine‡s183 Immune response§
HDMPContraindicatedYesYesYes¶≥1 months184 Therapy stopped**≥2–4 weeks‡May be reduceds185
InterferonStrict indicationYesYesYes¶Anytimes186 Anytime≥2–4 weeks‡Similars187
Glatiramer acetateStrict indicationYesYesYes¶Anytimes186 Anytime≥2–4 weeks‡Similars188
Dimethyl fumarateStrict indicationYesYesYes¶Not specifiedAnytime≥2–4 weeks‡Similars189
TeriflunomideContraindicatedYesYesYes¶≥6 monthss190††Anytime≥2–4 weeks‡Slightly reduced s191,s192
S1P modulators‡‡ContraindicatedYesYesYes¶≥2 monthss193 Anytime≥2–4 weeks‡Reduceds194–s196
NatalizumabContraindicatedYesYesYes¶≥3 monthss186 Anytime≥2–4 weeks‡Similars197,s198
B cell-depleting agents§§ContraindicatedYesYesYes¶Specified¶¶≥3–6 months***≥2–4 weeks‡Reduceds196,s199,s200
AlemtuzumabContraindicatedYesYesYes¶Not specifieds178,s201≥3–6 months***≥2–4 weeks‡Reduceds202
CladribineContraindicatedYesYesYes¶Specified†††Specified‡‡‡≥2–4 weeks‡Similars196,s203
MitoxantroneContraindicatedYesYesYes¶≥3 monthss204 Not specified≥2–4 weeks‡May be reduceds178,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 possibles184 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.