Key points
- Complement inhibitor therapy greatly raises the risk of meningococcal disease.
- Antibiotic prophylaxis might lower the risk.
- Vaccination is recommended, but protects only partly.
- Stay highly alert to meningococcal symptoms in these patients.
The risk
People taking complement inhibitors face a risk of meningococcal disease up to 2,000 times that of otherwise healthy people. The drugs include:
- C5 inhibitors, such as eculizumab and ravulizumab;
- inhibitors of other complement components, such as pegcetacoplan and iptacopan.
Their FDA-approved prescribing information carries a black box warning about meningococcal disease, including a recommendation to vaccinate patients.
Vaccines don't fully protect
CDC data suggest meningococcal vaccines likely give incomplete protection against invasive disease in people taking eculizumab, and experts think the same likely holds for other C5 inhibitors. Most infections in eculizumab patients were caused by nongroupable Neisseria meningitidis, which rarely causes invasive disease in people with normal immune systems. More: High Risk for Invasive Meningococcal Disease Among Patients Receiving Eculizumab (Soliris) Despite Receipt of Meningococcal Vaccine.
Antibiotic prophylaxis, on top of vaccination, could be considered to reduce risk — but patients on C5 inhibitors likely stay at substantially increased risk even when vaccinated, on prophylaxis, or both.
What clinicians should do
Educate every patient on a complement inhibitor so they:
- know the symptoms of meningococcal disease;
- understand their higher risk;
- seek care at once if symptoms start;
- get rapid treatment.
Stay suspicious: consider meningitis or meningococcemia in any of these patients with symptoms — even if symptoms look mild, the patient is fully vaccinated and up to date on boosters, or is taking prophylaxis.
Vaccinate: CDC recommends both MenACWY and MenB vaccines. Ideally, finish or update them at least 2 weeks before the first dose of the complement inhibitor — though therapy can start first if delaying it is riskier than the chance of meningococcal disease.
| Vaccine | Initial series | Boosters | Covers |
|---|---|---|---|
| MenACWY | 2, 3 or 4 doses, by brand and age | every 5 years while on therapy | serogroups A, C, W and Y; not nongroupable strains |
| MenB | 3 doses | 1 year after the series, then every 2 to 3 years while on therapy | serogroup B; protection against nongroupable strains not systematically assessed |
More: meningococcal vaccine recommendations; vaccine schedules for children and adolescents and adults; information for patients.
Conditions treated with complement inhibitors include atypical hemolytic uremic syndrome, generalized myasthenia gravis, neuromyelitis optica spectrum disorder and paroxysmal nocturnal hemoglobinuria.
Sources
Based on "Clinical Guidance for Managing Meningococcal Disease Risk in Patients Receiving Complement Inhibitor Therapy," Centers for Disease Control and Prevention; a work of the United States government in the public domain.
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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