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Most multiple sclerosis (MS) patients should receive recommended vaccinations, including yearly flu shots, according to an updated American Academy of Neurology (AAN) guideline about immunization and MS.

MS patients may have concerns about receiving immunizations, guideline panelists noted. Studies have shown that infections may trigger MS relapses, increase MS radiologic and immunologic activity, and accelerate disease progression, but selected reports have tied immunizations to clinical exacerbations of MS, the authors noted.

The guideline was published Wednesday in .

"We reviewed all of the available evidence and for people with MS, preventing infections through vaccine use is a key part of medical care," lead author Mauricio Farez, MD, MPH, of the FLENI Institution in Buenos Aires, Argentina, said in a statement. "People with MS should feel safe and comfortable getting their recommended vaccinations."

The new guidance updates one from 2002 and incorporates new evidence, vaccines, and disease-modifying therapies (DMTs). To create it, the panel conducted a systematic literature review, evaluating clinical trials, cohort studies, and case-control studies published from 1990 to March 2018 about the incidence, prevalence, and effect of vaccine-preventable disease and immunizations on MS. They included studies about DMTs and immunization effectiveness, and excluded case reports and case series except those providing safety data or using a laboratory reference standard.

From that review, the panel developed the following recommendations for clinicians:

• Discuss the evidence about immunizations in MS with patients and ask about their opinions and preferences.
• Recommend patients follow all local vaccine standards, unless there are specific contraindications, and weigh local vaccine-preventable disease risks.
• Counsel patients about infection risks of specific immunosuppressive or immunomodulating (ISIM) drugs according to prescribing information and vaccinate patients as needed at least 4 to 6 weeks before starting ISIM therapy. ISIM drugs include alemtuzumab (Lemtrada), dimethyl fumarate (Tecfidera), fingolimod (Gilenya), mitoxantrone, natalizumab (Tysabri), ocrelizumab (Ocrevus), rituximab (Rituxan), and teriflunomide (Aubagio).
• Recommend yearly flu shots unless there is a specific contraindication.
• Screen for infections before starting ISIM treatment -- including hepatitis, tuberculosis, and varicella zoster virus -- according to prescribing information and treat patients who test positive for latent infections.
• In patients at high risk for infection, screen and (if necessary) treat even when prescribing information does not call for it; consult infectious disease or other specialists about treating patients who screen positive for latent infection before treating them with ISIM drugs.
• Recommend against using live-attenuated vaccines in patients using ISIM therapies.
• Delay vaccinating patients who are experiencing an MS relapse.

"After reviewing all the available evidence, we found that there is not enough information to say whether or not vaccinations trigger or worsen MS flares," Farez noted. "Still, experts in MS urge their patients to hold off on scheduling their vaccinations if they are having an MS flare simply to avoid the potential for any complications."

The AAN also recommended that people with MS let their doctors know what DMTs they are using before being vaccinated; some vaccinations might be less effective depending on the MS treatment.

New ISIM treatments for MS are rapidly being developed and some have no immunization evidence yet, the panelists pointed out. "However, because some of these agents have similar mechanisms of action, the guideline panel believes that the recommendations here are sufficiently broad," they wrote. "The panel encourages review of manufacturer product information before the use of specific agents for immunization-related recommendations."

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