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Difficulty: MediumPreventive Care and Screening

A dermatologist refers a 58-year-old woman to the primary care clinic to optimize her preventive health measures. She has a 10-year history of severe plaque psoriasis that is currently well controlled with adalimumab monotherapy. She has no other medical conditions and does not use tobacco or alcohol. Her surgical history is notable for an uncomplicated appendectomy in her twenties. She reports having a painful episode of shingles on her right flank three years ago. Review of her records shows that a screening mammogram and a co-testing cervical cancer screening (Pap smear and HPV testing) were both performed one year ago with normal results. Her last screening colonoscopy was at age 50 and was entirely normal. Her immunizations are up to date for annual influenza, and a tetanus-diphtheria-acellular pertussis (Tdap) booster was given four years ago. She has not received any pneumococcal or zoster vaccinations. Which of the following is the most appropriate next step in this patient's preventive management?

  1. Administer the recombinant zoster vaccineAnswer
  2. B
    Discontinue adalimumab for four weeks before administering the recombinant zoster vaccine
  3. C
    Administer the 23-valent pneumococcal polysaccharide vaccine
  4. D
    Schedule a screening colonoscopy
  5. E
    Perform a dual-energy x-ray absorptiometry scan

Answer

Administer the recombinant zoster vaccine
The recombinant zoster vaccine is an inactivated vaccine recommended for all adults aged 50 years and older to prevent herpes zoster and postherpetic neuralgia. It is also explicitly recommended for adults aged 19 years and older who are immunosuppressed due to disease or therapy, such as those taking tumor necrosis factor (TNF) inhibitors like adalimumab. A prior episode of herpes zoster is not a contraindication; vaccination is still indicated to prevent future recurrences. Because the recombinant vaccine is not live, it is safe to administer to immunosuppressed patients without altering or holding their current medication regimen.

Step-by-Step Solution

1
Analyze the patient's demographic and clinical profile
The patient is a 58-year-old female taking adalimumab (a tumor necrosis factor inhibitor) for psoriasis, rendering her pharmacologically immunosuppressed.
Age and immune status dictate specific screening and vaccination requirements.
2
Evaluate her preventive care history
Mammogram and Pap/HPV were normal 1 year ago (up to date). Colonoscopy was normal at age 50 (due at age 60). She lacks pneumococcal and zoster vaccines.
Identifies gaps in preventive care that need to be addressed at the current visit.
3
Determine appropriate vaccine interventions for an immunosuppressed adult
She requires both pneumococcal and zoster vaccinations. However, the correct initial pneumococcal vaccine must be a conjugate vaccine (PCV20 or PCV15), not the polysaccharide one (PPSV23).
Vaccine sequencing guidelines strictly mandate a conjugate vaccine first for vaccine-naive individuals.
4
Apply zoster vaccine guidelines considering her medication and history
The recombinant zoster vaccine is indicated. Because it is inactivated, it can be safely given concurrently with adalimumab. Her prior episode of shingles does not preclude vaccination.
Guidelines recommend vaccination to prevent recurrent episodes, and inactivated vaccines do not require holding biologic therapies.

Key Concept

Adult immunization schedules and contraindications in immunosuppressed patients
Estimated Time:1m 30s
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Topics

Preventive Care and Screening

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