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Källmark H, Bergström T, Nagel J, Gullstrand B, Einarsson JT, Bengtsson AA, Kapetanovic MC. Serologic immunogenicity and safety of herpes zoster subunit vaccine in patients with rheumatoid arthritis receiving Janus kinase inhibitors. Rheumatology (Oxford) 2024; 63:2024-2033. [PMID: 37851412 PMCID: PMC11215978 DOI: 10.1093/rheumatology/kead552] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/12/2023] [Accepted: 09/21/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE Patients with RA treated with Janus kinase inhibitors (JAKis) are at increased risk of herpes zoster (HZ). The objective of this study was to investigate the serological immunogenicity and safety of the HZ subunit (HZ/su) vaccine in RA patients treated with JAKi, for which little is known. METHODS RA patients treated with JAKi (n = 82) at the Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden, and healthy controls (n = 51) received two doses of the HZ/su vaccine (Shingrix). Vaccine-specific antibody responses were analysed using indirect ELISA. Post-vaccination antibody levels were compared between patients and controls using analysis of covariance. Potential predictors for vaccine response were investigated using a multivariable linear regression analysis. Self-reported adverse events (AEs) and changes in RA disease activity were analysed. RESULTS Following vaccination, vaccine-specific antibody levels increased significantly in both patients and controls (P < 0.0001). A total of 80.5% of patients and 98.0% of controls achieved a ≥4-fold increase in antibody levels. Post-vaccination antibody levels were lower in patients than controls [ratio 0.44 (95% CI 0.31, 0.63)] and lower in patients receiving JAKi + methotrexate than JAKi monotherapy [ratio 0.43 (95% CI 0.24, 0.79)]. AEs, mostly mild/moderate, were common. One patient developed HZ and six patients (6.5%) had increased RA disease activity following vaccination. CONCLUSION The HZ/su vaccine was serologically immunogenic in most RA patients treated with JAKi. Moreover, the vaccine had an acceptable safety profile. These results support recommendations for use of the HZ/su vaccine in this vulnerable population. TRIAL REGISTRATION ClinicalTrials.gov (https://clinicaltrials.gov), NCT03886038.
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Affiliation(s)
- Hanna Källmark
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Tomas Bergström
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna Nagel
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Birgitta Gullstrand
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Jon T Einarsson
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Anders A Bengtsson
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Meliha C Kapetanovic
- Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund and Malmö, Sweden
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2
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Kostopoulou M, Mukhtyar CB, Bertsias G, Boumpas DT, Fanouriakis A. Management of systemic lupus erythematosus: a systematic literature review informing the 2023 update of the EULAR recommendations. Ann Rheum Dis 2024:ard-2023-225319. [PMID: 38777375 DOI: 10.1136/ard-2023-225319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To analyse the new evidence (2018-2022) for the management of systemic lupus erythematosus (SLE) to inform the 2023 update of the European League Against Rheumatism (EULAR) recommendations. METHODS Systematic literature reviews were performed in the Medline and the Cochrane Library databases capturing publications from 1 January 2018 through 31 December 2022, according to the EULAR standardised operating procedures. The research questions focused on five different domains, namely the benefit/harm of SLE treatments, the benefits from the attainment of remission/low disease activity, the risk/benefit from treatment tapering/withdrawal, the management of SLE with antiphospholipid syndrome and the safety of immunisations against varicella zoster virus and SARS-CoV2 infection. A Population, Intervention, Comparison and Outcome framework was used to develop search strings for each research topic. RESULTS We identified 439 relevant articles, the majority being observational studies of low or moderate quality. High-quality randomised controlled trials (RCTs) documented the efficacy of the type 1 interferon receptor inhibitor, anifrolumab, in non-renal SLE, and belimumab and voclosporin, a novel calcineurin inhibitor, in lupus nephritis (LN), when compared with standard of care. For the treatment of specific organ manifestations outside LN, a lack of high-quality data was documented. Multiple observational studies confirmed the beneficial effects of attaining clinical remission or low disease activity, reducing the risk for multiple adverse outcomes. Two randomised trials with some concerns regarding risk of bias found higher rates of relapse in patients who discontinued glucocorticoids (GC) or immunosuppressants in SLE and LN, respectively, yet observational cohort studies suggest that treatment withdrawal might be feasible in a subset of patients. CONCLUSION Anifrolumab and belimumab achieve better disease control than standard of care in extrarenal SLE, while combination therapies with belimumab and voclosporin attained higher response rates in high-quality RCTs in LN. Remission and low disease activity are associated with favourable long-term outcomes. In patients achieving these targets, GC and immunosuppressive therapy may gradually be tapered. Cite Now.
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Affiliation(s)
- Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete, School of Medicine, Heraklion, Greece
- Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Stefanizzi P, Moscara L, Palmieri C, Martinelli A, Di Lorenzo A, Venerito V, Germinario CA, Tafuri S. Safety profile of recombinant adjuvanted anti-herpes zoster vaccine (RZV) in high-risk groups: Data from active surveillance program. Puglia (Italy), 2021-23. Vaccine 2024; 42:2966-2974. [PMID: 38582693 DOI: 10.1016/j.vaccine.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Since 2021 a recombinant adjuvanted anti-Herpes Zoster vaccine(Recombinant Zoster Vaccine, RZV) is offered in Italy to high-risk patients. Few real-life data about RZV safety are available in target populations. OBJECTIVES This study investigates Adverse Events Following Immunization(AEFIs), baseline disease flare-ups, and Herpes Zoster (HZ) episodes occurring after RZV administration in a heterogeneous population of fragile patients to design its safety profile. METHODS This is a retrospective population-based study. RZV-vaccinated patients at Bari Policlinico General Hospital vaccination clinic from October 1st, 2021, to March 31st, 2023, were enrolled. Subjects were screened for reason of RZV eligibility and baseline chronic pathologies. AEFIs occurred in the first 7-days post-vaccination period were collected, and baseline disease flare-ups and post-vaccination HZ episodes were assessed via a 3-month follow-up. RESULTS Five-hundred-thirty-eight patients were included and total of 1,031 doses were administered. Most patients were vaccinated due to ongoing immunosuppressive therapy(54.65 %); onco-hematological and cardiovascular conditions were the most common chronic baseline pathologies. Out of 1,031 follow-ups, 441 AEFI cases were reported(42.7/100). The most common symptoms were injection site pain/itching(35.60/100), asthenia/malaise(11.44/100), and fever (10.09/100). Four serious AEFIs occurred(0.38/100). Older age, male sex, and history of cardiovascular diseases(OR:0.71; 95CI:0.52-0.98; p-value <0.05) were found to decrease AEFIs risk, while endocrine-metabolic illnesses(OR:1.61; 95CI:1.15-2.26; p-value <0.05) increased it. Twelve patients(2.23 %) reported a flare-up/worsening of their baseline chronic condition within the first three months after vaccination(mean interval 31.75 days, range 0-68 days). Patients with rheumatological illnesses had a higher risk of relapse(OR:16.56; 95CI:3.58-76.56; p-value <0.001), while male sex behaved as a protective factor. Twelve patients who completed the vaccination cycle(2.43%) had at least one HZ episode by the long-term follow-up. CONCLUSIONS The study demonstrates RZV safety in a significant number of high-risk patients. Hence, RZV should be actively offered as part of tailored vaccination programs to decrease the burden of HZ in fragile populations.
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Affiliation(s)
- Pasquale Stefanizzi
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy.
| | - Lorenza Moscara
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Claudia Palmieri
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Andrea Martinelli
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Di Lorenzo
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Vincenzo Venerito
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Cinzia Annatea Germinario
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Silvio Tafuri
- Hygiene Unit - Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
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Law J, Sorrento C, Saxena A. Vaccination updates and special considerations for systemic lupus erythematosus patients. Curr Opin Rheumatol 2024; 36:148-153. [PMID: 37976046 DOI: 10.1097/bor.0000000000000992] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW We review the latest guidelines and note special considerations for systemic lupus erythematosus (SLE) patients when approaching vaccination against SARS-CoV-2, influenza, pneumococcus, herpes zoster, and potentially respiratory syncytial virus (RSV) vaccine in the future. RECENT FINDINGS SLE patients have unique infectious risks due to newer treatments and the nature of the disease itself. It is important to balance the benefit of additional protective immunity from updated vaccines against the possible risk of disease activity exacerbations. SUMMARY It is important to continuously evaluate the safety and immunogenicity of updated vaccines specifically for SLE patients. Additionally, the newly approved RSV vaccine should be considered for this population to reduce severe respiratory illness.
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Affiliation(s)
- Jammie Law
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
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Kojima S, Iwamoto T, Kobayashi Y, Kato M, Takizawa F, Ida T, Suzuki J, Toda Y, Miyachi K, Iwata A, Furuta S, Ikeda K, Nakajima H. Immunogenicity and influence on disease activity of recombinant zoster vaccine in patients with rheumatoid arthritis treated with DMARDs. RMD Open 2024; 10:e003902. [PMID: 38388170 PMCID: PMC10882334 DOI: 10.1136/rmdopen-2023-003902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/01/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES This study aimed to determine the immunogenicity and the influence on disease activity of an adjuvanted recombinant varicella-zoster virus (VZV) subunit vaccine (RZV) in patients with rheumatoid arthritis (RA) treated with disease-modifying antirheumatic drugs (DMARDs). METHODS This prospective longitudinal study enrolled 53 patients with RA (aged ≥50 years) treated with DMARDs (conventional synthetic (cs)DMARDs 20, biological (b)DMARDs 23 and targeted synthetic (ts)DMARDs 10) and 10 control individuals. The participants received two intramuscular RZV 2 months apart. VZV-specific CD4+ T cell responses (cell-mediated immunity; CMI) and IgG antibody responses (humoral immunity; HI) were assessed at 0 and 3 months after the first RZV administration using flow cytometry and enzyme immunoassay, respectively. Disease activity (Disease Activity Score 28-C reactive protein and Clinical Disease Activity Index), flares and adverse events were monitored for 6 months after the first vaccination. RESULTS VZV-specific CMI and HI significantly increased in the three DMARDs-treated patients with RA after RZV administration compared with the corresponding prevaccination values (p<0.001-0.014), and the magnitudes and fold-increases of those responses were not significantly different among the three DMARDs-treated patients with RA. Furthermore, the vaccine response rates of CMI and HI were not significantly different between csDMARDs-treated patients and b-DMARDs or ts-DMARDs-treated patients. Meanwhile, no significant increases in disease activity indices or adverse events were observed in these patients during the 6-month follow-up period after the first vaccination. RZV-induced RA flares occurred in two patients (3.8%) but were mild and controllable. CONCLUSION RZV is robustly immunogenic and has a clinically acceptable safety profile in elderly patients with RA receiving DMARDs.
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Affiliation(s)
- Shotaro Kojima
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Taro Iwamoto
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Yoshihisa Kobayashi
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Manami Kato
- Department of Internal Medicine, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Fumiyoshi Takizawa
- Department of Internal Medicine, Seikeikai Chiba Medical Center, Chiba, Japan
| | - Tomoaki Ida
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Junya Suzuki
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Yosuke Toda
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Kazusa Miyachi
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Arifumi Iwata
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
- Department of Rheumatology, Dokkyo Medical University, Mibu, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
- Chiba University Synergy Institute for Futuristic Mucosal Vaccine Research and Development, Chiba, Japan
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6
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Bijl M, Westra J, Mancuso S, Bearzi P, Giacomelli R, Conti F. Should we vaccinate during an active rheumatic disease? Autoimmun Rev 2024; 23:103426. [PMID: 37634680 DOI: 10.1016/j.autrev.2023.103426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
Timing of vaccination and its relationship with concomitant immunosuppressive therapy has been a matter of debate in the field of AutoImmune Inflammatory Rheumatic Diseases (AIIRD). Vaccination is crucial in the prevention of infections, which, in the setting of AIIRD, are known risk factors for disease flare and expose patients to increase risk of complications and mortality. As evidenced from real-life studies, vaccines do not significantly affect disease activity. Conversely, disease activity (especially in Systemic Lupus Erythematosus) may predict for vaccine response: high disease activity correlates with decreased seroconversion. For this reason, according to the EULAR 2019 recommendation, vaccination should preferably be administered during quiescent AIIRD. Beside disease activity, background immunosuppressive therapy should be considered when performing vaccination, as different Disease Modifying Anti-Rheumatic Drugs (DMARDs) decrease vaccine immunogenicity. AIIRD patients should be vaccinated, independently from the vaccine type, before starting immunosuppression. If the patient is on active immunosuppressive therapy, the best window of opportunity to boost vaccine response is during AIIRD quiescence, as low disease activity increases seroconversion and allows safe immunosuppressant spacing. In conclusion, the majority of AIIRD patients should receive vaccination, preferably during quiescent disease and taking into consideration immunosuppressant spacing.
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Affiliation(s)
- Marc Bijl
- Department of Internal Medicine and Rheumatology, Martini Hospital, Groningen, the Netherlands
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands
| | - Silvia Mancuso
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari Sapienza University of Rome, Rome, Italy
| | - Pietro Bearzi
- Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
| | - Roberto Giacomelli
- Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy; Clinical and Research Section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Via Álvaro del Portillo 200, 00128 Rome, Italy.
| | - Fabrizio Conti
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari Sapienza University of Rome, Rome, Italy
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Parikh R, Singer D, Chmielewski-Yee E, Dessart C. Effectiveness and safety of recombinant zoster vaccine: A review of real-world evidence. Hum Vaccin Immunother 2023; 19:2263979. [PMID: 37967254 PMCID: PMC10653743 DOI: 10.1080/21645515.2023.2263979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/23/2023] [Indexed: 11/17/2023] Open
Abstract
The recombinant zoster vaccine (RZV) was licensed in the US for prevention of herpes zoster (HZ) in 2017. We conducted a literature search (January 1, 2017-August 1, 2023) using PubMed, Embase, and Scopus to consolidate the real-world evidence related to RZV. Overall, RZV effectiveness against HZ was high across the studied populations in real-world settings, including adults aged ≥ 50 years and patients aged ≥ 18 years with immunodeficiency or immunosuppression. Effectiveness was higher with two doses versus one dose, especially in elderly people and immunocompromised individuals. The safety profile of RZV was broadly consistent with that established in clinical trials. RZV does not appear to increase the risk of disease flares in patients with immune-mediated diseases. Approximately two-thirds of individuals received a second RZV dose within 2-6 months after the first dose. Collectively, RZV effectiveness against HZ was high, and these real-world studies reaffirm its favorable benefit-risk profile.
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Affiliation(s)
| | - David Singer
- US Health Outcomes and Epidemiology, GSK, Philadelphia, PA, USA
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Alnaimat F, Sweis JJG, Jansz J, Modi Z, Prasad S, AbuHelal A, Vagts C, Hanson HA, Ascoli C, Novak RM, Papanikolaou IC, Rubinstein I, Sweiss N. Vaccination in the Era of Immunosuppression. Vaccines (Basel) 2023; 11:1446. [PMID: 37766123 PMCID: PMC10537746 DOI: 10.3390/vaccines11091446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with autoimmune inflammatory rheumatic diseases (AIIRDs) are at increased risk for severe infections. Vaccine responses and safety profiles may differ between AIIRD patients and the general population. While patients with autoimmune inflammatory rheumatic diseases (AIIRDs) often experience diminished humoral responses and reduced vaccine efficacy, factors such as the type of immunosuppressant medications used and the specific vaccine employed contribute to these outcomes. Notably, individuals undergoing B cell depletion therapy tend to have poor vaccine immunogenicity. However, despite these considerations, vaccine responses are generally considered clinically sufficient. Ideally, immunosuppressed AIIRD patients should receive vaccinations at least two weeks before commencing immunosuppressive treatment. However, it is common for many patients to already be on immunosuppressants during the immunization process. Vaccination rarely triggers flares in AIIRDs; if flares occur, they are typically mild. Despite the heightened infection risk, including COVID-19, among AIIRD patients with rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, and other diseases on immunosuppressants, the vaccination rates remain suboptimal. The future directions of vaccination in the era of immunosuppression will likely involve customized vaccines with enhanced adjuvants and alternative delivery methods. By addressing the unique challenges faced by immunosuppressed individuals, we may improve vaccine efficacy, reduce the risk of infections, and ultimately enhance the health outcomes. Additionally, clinical trials to evaluate the safety and efficacy of temporarily discontinuing immunosuppressants during vaccination in various AIIRDs are crucial.
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Affiliation(s)
- Fatima Alnaimat
- Department of Internal Medicine, Division of Rheumatology, School of Medicine, University of Jordan, Amman 11942, Jordan
| | | | - Jacqueline Jansz
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | - Zeel Modi
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | - Supritha Prasad
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | | | - Christen Vagts
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Hali A. Hanson
- College of Pharmacy, University of Illinois Hospital & Health Sciences System, Chicago, IL 60612, USA;
| | - Christian Ascoli
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Richard M. Novak
- Division of Infectious Diseases, University of Illinois, Chicago, IL 60612, USA;
| | - Ilias C. Papanikolaou
- Department of Respiratory Medicine, Sarcoidosis Clinic, Corfu General Hospital, 49100 Corfu, Greece;
| | - Israel Rubinstein
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Nadera Sweiss
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA;
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Wroński J, Ciechomska M, Kuca-Warnawin E. Impact of methotrexate treatment on vaccines immunogenicity in adult rheumatological patients - Lessons learned from the COVID-19 pandemic. Biomed Pharmacother 2023; 165:115254. [PMID: 37542854 DOI: 10.1016/j.biopha.2023.115254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023] Open
Abstract
Despite the development of new biological and synthetic targeted therapies, methotrexate remains one of the most commonly used immunomodulatory drugs in rheumatology. However, its effect on the immunogenicity of vaccines has been studied only to a limited extent until recently, resulting in the lack of clear guidelines on the use of methotrexate during vaccination. Significant progress was made during the COVID-19 pandemic due to the dynamic development of research on vaccines, including patients with autoimmune inflammatory rheumatic diseases. In the following literature review, we present a summary of what we know so far on the impact of methotrexate on post-vaccination response in adult rheumatology patients, taking into account the lessons learned from the COVID-19 pandemic. Studies on the effect of methotrexate on the immunogenicity of influenza, pneumococcal, herpes zoster, tetanus/diphtheria/pertussis, hepatitis A, yellow fever, and COVID-19 vaccines are described in detail, including the effect of methotrexate on the humoral and cellular response of individual vaccines. The available evidence for recommendations for withholding methotrexate in the post-vaccination period is presented. Lastly, an overview of potential immunological mechanisms through which MTX modulates the immunogenicity of vaccinations is also provided.
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Affiliation(s)
- Jakub Wroński
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland.
| | - Marzena Ciechomska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
| | - Ewa Kuca-Warnawin
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
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Mortezavi M, Mysler EF. Clinical scenarios-based guide for tofacitinib in rheumatoid arthritis. Ther Adv Chronic Dis 2023; 14:20406223231178273. [PMID: 37360417 PMCID: PMC10286162 DOI: 10.1177/20406223231178273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/02/2023] [Indexed: 06/28/2023] Open
Abstract
Tofacitinib was the first Janus kinase inhibitor to be approved for the treatment of rheumatoid arthritis (RA), and there is a large body of data to inform the efficacy and safety of this drug for patients at different places in their treatment journeys and with diverse demographics and characteristics. Here, we summarize tofacitinib clinical efficacy and safety data from some clinical trials, post hoc analyses, and real-world studies, which provide evidence of the efficacy of tofacitinib in treating patients with RA at various stages of their treatment journeys, and with differentiating baseline characteristics, such as age, gender, race, and body mass index. In addition, we review the safety data available from different patient subpopulations in the tofacitinib clinical development program, real-world data, and findings from the ORAL Surveillance post-marketing safety study that included patients aged ⩾50 years with pre-existing cardiovascular risk factors. The available efficacy and safety data in these subpopulations can enable better discussions between clinicians and patients to guide informed decision-making and individualized patient care.
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Prontskus V, Fresse A, Yelehe-Okouma M, Facile A, Pietri T, Simon C, Le Souder C, Beurrier M, Gillet P. COVID-19 Vaccination and the Incidence of De Novo or Recurrent Rheumatoid Arthritis: A French and International (VigiBase) Signal Detection Study. Clin Pharmacol Ther 2023; 113:1107-1116. [PMID: 36752604 DOI: 10.1002/cpt.2866] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
COVID-19 vaccination is critical in frequently immunocompromised patients with rheumatoid arthritis (RA). However, there is a question about the risk of RA flares following vaccination. Our study intended to find out about cases of new RA or flare-ups in people who already had RA that were reported in French and international pharmacovigilance databases after COVID-19 vaccination. We performed a "case-noncase" method in the international pharmacovigilance database VigiBase to identify the risk of RA following COVID-19 vaccination compared with other nonlive vaccines. Using the French Pharmacovigilance Database (FPVD), a descriptive analysis was carried out for RA cases after COVID-19 immunization and a multivariate logistic regression analysis was conducted to compare variables in the new-onset vs. flare-up groups. In 2021, 2,387 cases of RA were reported from 2,817,902 adverse drug reactions associated with COVID-19 vaccines recorded in VigiBase. The reporting odds ratio of RA onset with COVID-19 vaccines compared with the other nonlive vaccines was 0.66 (P < 0.0001). The FPVD reported 161 cases of RA with COVID-19 vaccines, including 77 new-onset RA and 84 cases of RA flare-up. In 88 cases (84.7%), RA occurred after the first dose. The mean time between vaccination and disease onset was 14 ± 21 days, and the delay was significantly shorter in the flare-up group. We do not show a higher risk of RA after COVID-19 vaccination compared with other nonlive vaccines in adults. De novo RA was more likely to happen quickly, be more severe, and have a worse outcome than flares in patients with RA.
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Affiliation(s)
- Viktoryia Prontskus
- Laboratoire de Pharmacologie-Toxicologie, Pharmacovigilance & Centre d'évaluation et d'information sur la Pharmacodépendance-Addictovigilance, Centre Hospitalier Régional et Universitaire de Nancy Brabois, Bâtiment de Biologie Médicale et de Biopathologie, Vandœuvre-Lès-Nancy, France
| | - Audrey Fresse
- Laboratoire de Pharmacologie-Toxicologie, Pharmacovigilance & Centre d'évaluation et d'information sur la Pharmacodépendance-Addictovigilance, Centre Hospitalier Régional et Universitaire de Nancy Brabois, Bâtiment de Biologie Médicale et de Biopathologie, Vandœuvre-Lès-Nancy, France
| | - Mélissa Yelehe-Okouma
- Laboratoire de Pharmacologie-Toxicologie, Pharmacovigilance & Centre d'évaluation et d'information sur la Pharmacodépendance-Addictovigilance, Centre Hospitalier Régional et Universitaire de Nancy Brabois, Bâtiment de Biologie Médicale et de Biopathologie, Vandœuvre-Lès-Nancy, France
| | - Anthony Facile
- Service Hospitalo-Universitaire de Pharmacotoxicologie, Hospices Civils de Lyon, Lyon, France
| | - Tessa Pietri
- Centre Régional de Pharmacovigilance Marseille Provence Corse, Service de Pharmacologie Clinique & Pharmacovigilance, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université Institut National de la Santé et de la Recherche Médicale 1106, Marseille, France
| | - Corinne Simon
- Centre Régional de Pharmacovigilance, Service de Pharmacosurveillance, Centre Hospitalier Régional et Universitaire, Tours, France
| | - Cosette Le Souder
- Département de Pharmacologie Médicale et Toxicologie, Centre Régional de Pharmacovigilance Occitanie-Est, Le Centre Hospitalier et Universitaire de Montpellier, Montpellier, France
| | - Mathilde Beurrier
- Laboratoire de Pharmacologie-Toxicologie, Pharmacovigilance & Centre d'évaluation et d'information sur la Pharmacodépendance-Addictovigilance, Centre Hospitalier Régional et Universitaire de Nancy Brabois, Bâtiment de Biologie Médicale et de Biopathologie, Vandœuvre-Lès-Nancy, France
| | - Pierre Gillet
- Laboratoire de Pharmacologie-Toxicologie, Pharmacovigilance & Centre d'évaluation et d'information sur la Pharmacodépendance-Addictovigilance, Centre Hospitalier Régional et Universitaire de Nancy Brabois, Bâtiment de Biologie Médicale et de Biopathologie, Vandœuvre-Lès-Nancy, France
- Université de Lorraine, Centre National de la Recherche Scientifique, Ingénierie Moléculaire et Physiopathologie Articulaire, Nancy, France
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Venerito V, Stefanizzi P, Cantarini L, Lavista M, Galeone MG, Di Lorenzo A, Iannone F, Tafuri S, Lopalco G. Immunogenicity and Safety of Adjuvanted Recombinant Zoster Vaccine in Rheumatoid Arthritis Patients on Anti-Cellular Biologic Agents or JAK Inhibitors: A Prospective Observational Study. Int J Mol Sci 2023; 24:ijms24086967. [PMID: 37108130 PMCID: PMC10138868 DOI: 10.3390/ijms24086967] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/06/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023] Open
Abstract
Rheumatoid arthritis (RA) patients on JAK inhibitors (JAKi) have an increased HZ risk compared to those on biologic DMARDs (bDMARDs). Recently, the Adjuvanted Recombinant Zoster Vaccine (RZV) became available worldwide, showing good effectiveness in patients with inflammatory arthritis. Nevertheless, direct evidence of the immunogenicity of such a vaccine in those on JAKi or anti-cellular bDMARDs is still lacking. This prospective study aimed to assess RZV immunogenicity and safety in RA patients receiving JAKi or anti-cellular bDMARDs that are known to lead to impaired immune response. Patients with classified RA according to ACR/EULAR 2010 criteria on different JAKi or anti-cellular biologics (namely, abatacept and rituximab) followed at the RA clinic of our tertiary center were prospectively observed. Patients received two shots of the RZV. Treatments were not discontinued. At the first and second shots, and one month after the second shot, from all patients with RA, a sample was collected and RZV immunogenicity was assessed and compared between the treatment groups and healthy controls (HCs) receiving RZV for routine vaccination. We also kept track of disease activity at different follow-up times. Fifty-two consecutive RA patients, 44 females (84.61%), with an average age (±SD) of 57.46 ± 11.64 years and mean disease duration of 80.80 ± 73.06 months, underwent complete RZV vaccination between February and June 2022 at our center. At the time of the second shot (1-month follow-up from baseline), anti-VZV IgG titer increased significantly in both groups with similar magnitude (bDMARDs: 2258.76 ± 897.07 mIU/mL; JAKi: 2059.19 ± 876.62 mIU/mL, p < 0.001 for both from baseline). At one-month follow-up from the second shot, anti-VZV IgG titers remained stable in the bDMARDs group (2347.46 ± 975.47) and increased significantly in the JAKi group (2582.65 ± 821.59 mIU/mL, p = 0.03); still, no difference was observed between groups comparing IgG levels at this follow-up time. No RA flare was recorded. No significant difference was shown among treatment groups and HCs. RZV immunogenicity is not impaired in RA patients on JAKi or anti-cellular bDMARDs. A single shot of RZV can lead to an anti-VZV immune response similar to HCs without discontinuing DMARDs.
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Affiliation(s)
- Vincenzo Venerito
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
| | - Pasquale Stefanizzi
- Interdisciplinary Department of Medicine, Aldo Moro University of Bari, 70121 Bari, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, 53100 Siena, Italy
| | - Marlea Lavista
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
| | - Maria Grazia Galeone
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
| | - Antonio Di Lorenzo
- Interdisciplinary Department of Medicine, Aldo Moro University of Bari, 70121 Bari, Italy
| | - Florenzo Iannone
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
| | - Silvio Tafuri
- Interdisciplinary Department of Medicine, Aldo Moro University of Bari, 70121 Bari, Italy
| | - Giuseppe Lopalco
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Polyclinic Hospital, University of Bari, 70124 Bari, Italy
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COVID-19 Vaccination experience in patients with Rheumatoid Arthritis treated at a single VA Medical Center. Vaccine X 2023; 14:100295. [PMID: 37051228 PMCID: PMC10069931 DOI: 10.1016/j.jvacx.2023.100295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Background Following the introduction of the COVID-19 vaccines, there has been uncertainty as to whether receiving the COVID-19 vaccine will result in overactivation of the immune system and subsequently lead to an autoimmune disease flare. The purpose of this study was to assess whether rheumatoid arthritis (RA) patients who received the mRNA COVID-19 vaccine are at increased risk for disease flare. Methods We conducted a single-center retrospective and prospective study at the Louis Stokes Cleveland VA Medical Center between 12/2021 and 2/2022. We included 100 patients with rheumatoid arthritis (RA) who were actively on immunosuppressive therapy and received three doses of the Pfizer-BioNTech vaccine. A survey questionnaire was used to collect data about their RA and if they developed symptoms post vaccination. Our primary end point was to determine incidence of flare of RA after COVID-19 vaccine. Secondary end points were to estimate the side effect profile from the vaccine, and to check if patients developed a COVID-19 infection after they received the vaccine. Results None of the patients reported symptoms of RA flare within two months of receiving the 3 doses of the vaccine. Most common vaccine side effects were soreness over the injection site (n=14), headache (n=11), fatigue(n=7) and myalgias(n=4). 5 patients developed a COVID-19 infection prior to receiving the vaccine, 8 after being vaccinated, 3 of the 8 within 5 months from the second dose and 5 out of the 8 within 3 months from the third vaccine dose. Conclusion RA patients receiving the COVID-19 Pfizer mRNA vaccine do not appear to commonly develop major symptoms, flares or side effects following the vaccine. Further research with larger numbers of patients with rheumatoid arthritis as well as those with other autoimmune disease is needed to better understand the safety and effectiveness of COVID-19 vaccine.
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14
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Waldman RA, Sharp KL, Adalsteinsson JA, Grant-Kels JM. Herpes zoster subunit vaccine for patients initiating a Janus kinase inhibitor. J Am Acad Dermatol 2023; 88:697-698. [PMID: 36041555 DOI: 10.1016/j.jaad.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 08/21/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Reid A Waldman
- Dermatology Associates of Glastonbury, Glastonbury, Connecticut.
| | - Kelley L Sharp
- Quinnipiac University Frank H. Netter MD School of Medicine, North Haven, Connecticut
| | - Jonas A Adalsteinsson
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
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Hurley LP, O'Leary ST, Dooling K, Anderson TC, Crane LA, Cataldi JR, Brtnikova M, Beaty BL, Gorman C, Guo A, Lindley MC, Kempe A. Survey of Physician Practices, Attitudes, and Knowledge Regarding Recombinant Zoster Vaccine. J Gen Intern Med 2023; 38:986-993. [PMID: 35794307 PMCID: PMC9261227 DOI: 10.1007/s11606-022-07721-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/17/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Herpes zoster vaccination rates remain low despite longstanding national recommendations to vaccinate immunocompetent adults aged ≥ 50 years. The Advisory Committee on Immunization Practice (ACIP) updated its recommendations for recombinant zoster vaccine (RZV) in October 2021 to include immunocompromised adults aged ≥19 years. OBJECTIVE To assess practices, attitudes, and knowledge about RZV, barriers to recommending RZV, and likelihood of recommending RZV to patients with various immunocompromising conditions. DESIGN Mail and internet-based survey conducted from May through July 2020. PARTICIPANTS General internists and family physicians throughout the USA. MAIN MEASURES Survey responses. KEY RESULTS The response rate was 66% (632/955). Many physicians were already recommending RZV to immunocompromised populations, including adults ≥50 years with HIV (67% of respondents) and on recombinant human immune modulator therapy (56%). Forty-seven percent of respondents both stocked/administered RZV and referred patients elsewhere, frequently a pharmacy, for vaccination; 42% did not stock RZV and only referred patients. The majority agreed pharmacies do not inform them when RZV has been given (64%). Physicians were generally knowledgeable about RZV; however, 25% incorrectly thought experiencing side effects from the first dose of RZV that interfere with normal activities was a reason to not receive the second dose. The top reported barrier to recommending RZV was experience with patients declining RZV due to cost concerns (67%). Most physicians reported they would be likely to recommend RZV to immunocompromised patients. CONCLUSION Most primary care physicians welcome updated ACIP RZV recommendations for immunocompromised adults. Knowledge gaps, communication issues, and financial barriers need to be addressed to optimize vaccination delivery.
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Affiliation(s)
- Laura P Hurley
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA.
- Division of General Internal Medicine, Denver Health, Denver, CO, USA.
| | - Sean T O'Leary
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Kathleen Dooling
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tara C Anderson
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lori A Crane
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
- Department of Community and Behavioral Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jessica R Cataldi
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Michaela Brtnikova
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Carol Gorman
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Angela Guo
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Strategic Innovative Solutions, LLC, Atlanta, GA, USA
| | - Megan C Lindley
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Allison Kempe
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics University of Colorado Anschutz Medical Center, Aurora, CO, USA
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16
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Kobayashi S, Kusuda T, Kubo K. Reply to: Comment on "influence of COVID-19 vaccination on disease activity of rheumatoid arthritis in older patients". Geriatr Gerontol Int 2023; 23:155-156. [PMID: 36623914 DOI: 10.1111/ggi.14535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Satomi Kobayashi
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Takeshi Kusuda
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan.,Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kanae Kubo
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
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Sullivan KM, Farraye FA, Winthrop KL, Willer DO, Vink P, Tavares-Da-Silva F. Safety and efficacy of recombinant and live herpes zoster vaccines for prevention in at-risk adults with chronic diseases and immunocompromising conditions. Vaccine 2023; 41:36-48. [PMID: 36460534 DOI: 10.1016/j.vaccine.2022.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 11/30/2022]
Abstract
Compared with the general population, older adults with immune senescence and individuals who are immunocompromised (IC) due to disease or immunosuppressive therapy are at increased risk for herpes zoster (HZ) and its associated complications, which can be debilitating and life-threatening. Vaccination can be an effective strategy against HZ and studies have shown that HZ vaccination in IC individuals can elicit immune responses and provide protection from infection. Recently, the first approvals have been granted in the United States and the European Union for the recombinant HZ vaccine (RZV) in adults ≥ 18 years of age at risk of HZ due to immunodeficiency or immunosuppression. Existing systematic reviews have highlighted the risks for HZ in limited immunocompromising conditions and have only examined clinical data for RZV. This review details the risks and burden of HZ in a broad range of clinically relevant IC populations and summarizes key efficacy and safety data for RZV and live HZ vaccine in these individuals. Research has shown IC individuals can benefit from HZ vaccination; however, these insights have yet to be fully incorporated into vaccination guidelines and clinical care. Clinicians should consider HZ vaccination in eligible at-risk populations to protect against HZ and its associated complications and thereby, reduce the burden that HZ poses on the healthcare system. Electronic health records and linked personal health records could be used to identify and contact patients eligible for HZ vaccination and provide clinical decision support-generated alerts for missing or delayed vaccinations. This review will help clinicians identify eligible IC individuals who may benefit from HZ vaccination. A video abstract linked to this article is available on Figshare https://doi.org/10.6084/m9.figshare.21517605.
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Affiliation(s)
- Keith M Sullivan
- Duke University Medical Center, 200 Trent Dr, Durham, NC 27710, USA.
| | - Francis A Farraye
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Kevin L Winthrop
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, USA.
| | - David O Willer
- GSK Vaccines, 100 Milverton Drive Suite 800, Mississauga, ON, Canada.
| | - Peter Vink
- GSK Vaccines, 14200 Shady Grove Rd, Rockville, MD 20850, USA.
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Nakamura H, Nagasawa Y, Kobayashi H, Tsukamoto M, Takayama T, Kitamura N. Successful Treatment of SARS-CoV-2 Vaccination-related Activation of Rheumatoid Arthritis with Positive Findings for Epstein-Barr Virus. Intern Med 2022; 61:2073-2076. [PMID: 35466171 PMCID: PMC9334251 DOI: 10.2169/internalmedicine.9433-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We herein report a 60-year-old woman who experienced severe flare of rheumatoid arthritis (RA) and Epstein-Barr virus (EBV) positivity following administration of the messenger ribonucleic acid (mRNA)-type severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Since 40 years old, she had been in long-term remission of anti-citrullinated protein antibody-positive RA. Ten days after SARS-CoV-2 vaccination, she presented with a high fever and polyarthritis, active synovitis on joint ultrasound, a clinical disease activity index of 35, and positivity for anti-early antigen, diffuse type and restricted type (EA DR) IgG and EBV deoxyribonucleic acid (EBV-DNA). Tocilizumab was introduced to treat RA. The RA disease activity disappeared, and anti-EA DR IgG and EBV-DNA became negative.
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Affiliation(s)
- Hideki Nakamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Yosuke Nagasawa
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Hitomi Kobayashi
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Masako Tsukamoto
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Tadateru Takayama
- Division of General Medicine, Department of Medicine, Nihon University School of Medicine, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
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Leung J, Anderson TC, Dooling K, Xie F, Curtis JR. Recombinant Zoster Vaccine Uptake and Risk of Flares Among Older Adults with Immune-Mediated Inflammatory Diseases in the United States. Arthritis Rheumatol 2022; 74:1833-1841. [PMID: 35666070 DOI: 10.1002/art.42261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/24/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Persons with immune-mediated inflammatory diseases (IMIDs) are at increased risk of herpes zoster (HZ). In 2018, CDC recommended a highly efficacious vaccine, recombinant zoster vaccine (RZV), for prevention of HZ in immunocompetent ≥50 years-olds. We estimated RZV vaccination among adults age ≥50 years with IMIDs during 2018-2019 and examined possible vaccine-related flares following RZV. METHODS We identified a cohort of IMID patients using medical claims data from IBM® MarketScan® (age 50-64 years) and Centers for Medicare and Medicaid Services Medicare (age ≥65 years). Presumed flares were defined as hospitalization/emergency department visit for their respective IMIDs, or steroid treatment with a short-acting oral glucocorticoid or parenteral glucocorticoid injection. We conducted a self-controlled case series (SCCS) analysis to examine a temporal association between RZV and flares. RESULTS Among enrollees with IMIDs, 14.8% of 55,654 MarketScan and 43.2% of 160,545 Medicare enrollees received ≥1-dose of RZV during 2018-2019. Two-dose series completion was 76.6% in MarketScan and 85.4% in Medicare enrollees. In the SCCS analysis, 10% and 13% developed flares in the control as compared to 9% and 11-12% in the risk window following 1- or 2-doses of RZV among MarketScan and Medicare enrollees, respectively. We found no statistically significant increase in flares following RZV administration for any IMID in either age group following RZV dose-1 or dose-2. CONCLUSIONS We did not find an increase in presumed flares following RZV vaccination. Among adults aged ≥50 years with IMIDs, a substantial proportion received RZV compared to general zoster coverage estimates and series-completion was high. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jessica Leung
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Tara C Anderson
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kathleen Dooling
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
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Vaccination for the Prevention of Infection among Immunocompromised Patients: A Concise Review of Recent Systematic Reviews. Vaccines (Basel) 2022; 10:vaccines10050800. [PMID: 35632555 PMCID: PMC9144891 DOI: 10.3390/vaccines10050800] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/10/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023] Open
Abstract
Vaccination is crucial for avoiding infection-associated morbidity and mortality among immunocompromised patients. However, immunocompromised patients respond less well to vaccinations compared to healthy people, and little is known about the relative efficacy of various vaccines among different immunocompromised states. A total of 54 systematic reviews (22 COVID-19; 32 non-COVID-19) published within the last 5 years in Pubmed® were reviewed. They demonstrated similar patterns within three seroconversion response categories: good (about >60% when compared to healthy controls), intermediate (~40−60%), and poor (about <40%). Good vaccine responses would be expected for patients with chronic kidney disease, human immunodeficiency virus infection (normal CD4 counts), immune-mediated inflammatory diseases, post-splenectomy states, and solid tumors. Intermediate vaccine responses would be expected for patients with anti-cytotoxic T-lymphocyte antigen-4 therapy, hematologic cancer, and human immunodeficiency virus infection (low CD4 counts). Poor vaccine responses would be expected for patients with B-cell-depleting agents (e.g., anti-CD20 therapy), hematopoietic stem-cell transplant, solid organ transplant, and liver cirrhosis. For all vaccine response categories, vaccination should be timed when patients are least immunosuppressed. For the intermediate and poor vaccine response categories, high-dose vaccine, revaccination when patients are less immunosuppressed, checking for seroconversion, additional booster doses, and long-acting monoclonal antibodies may be considered, supplemented by shielding measures.
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Rider LG, Parks CG, Wilkerson J, Schiffenbauer AI, Kwok RK, Noroozi Farhadi P, Nazir S, Ritter R, Sirotich E, Kennedy K, Larche MJ, Levine M, Sattui SE, Liew JW, Harrison CO, Moni TT, Miller AK, Putman M, Hausmann J, Simard JF, Sparks JA, Miller FW. Baseline Factors Associated with Self-reported Disease Flares Following COVID-19 Vaccination among Adults with Systemic Rheumatic Disease: Results from the COVID-19 Global Rheumatology Alliance Vaccine Survey. Rheumatology (Oxford) 2022; 61:SI143-SI150. [PMID: 35460240 DOI: 10.1093/rheumatology/keac249] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/30/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To examine the frequency of, and risk factors for, disease flare following COVID-19 vaccination in patients with systemic rheumatic disease (SRD). METHODS An international study was conducted from April 2 to August 16, 2021, using an online survey of 5619 adults with SRD for adverse events following COVID-19 vaccination, including flares of disease requiring a change in treatment. We examined risk factors identified a priori based on published associations with SRD activity and SARS-CoV-2 severity, including demographics, SRD type, comorbidities, vaccine type, cessation of immunosuppressive medications around vaccination, and history of reactions to non-COVID-19 vaccines, using multivariable logistic regression. RESULTS Flares requiring a change in treatment following COVID-19 vaccination were reported by 4.9% of patients. Compared with rheumatoid arthritis, certain SRD, including systemic lupus erythematosus (OR 1.51, 95%CI 1.03, 2.20), psoriatic arthritis (OR 1.95, 95%CI 1.20, 3.18), and polymyalgia rheumatica (OR 1.94, 95%CI 1.08, 2.48) were associated with higher odds of flare, while idiopathic inflammatory myopathies were associated with lower odds for flare (OR 0.54, 95%CI 0.31-0.96). The Oxford-AstraZeneca vaccine was associated with higher odds of flare relative to the Pfizer-BioNTech vaccine (OR 1.44, 95%CI 1.07, 1.95), as were a prior reaction to a non-COVID-19 vaccine (OR 2.50, 95%CI 1.76, 3.54) and female sex (OR 2.71, 95%CI 1.55, 4.72). CONCLUSION SRD flares requiring changes in treatment following COVID-19 vaccination were uncommon in this large international study. Several potential risk factors, as well as differences by disease type, warrant further examination in prospective cohorts.
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Affiliation(s)
- Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
| | | | | | - Adam I Schiffenbauer
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
| | - Richard K Kwok
- Office of the Director, NIEHS, NIH, Research Triangle Park, NC, USA
| | - Payam Noroozi Farhadi
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
| | - Sarvar Nazir
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
| | | | | | - Kevin Kennedy
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | | | - Mitchell Levine
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Sebastian E Sattui
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean W Liew
- Section of Rheumatology, Boston University School of Medicine, Boston, MA, USA
| | | | - Tarin T Moni
- Department of Biochemistry and Biomedical Sciences, McMaster University Faculty of Science, Hamilton, ON, Canada
| | - Aubrey K Miller
- Office of the Director, NIEHS, NIH, Research Triangle Park, NC, USA
| | | | - Jonathan Hausmann
- Program in Rheumatology, Boston Children's Hospital, Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
| | - Julia F Simard
- Department of Epidemiology and Population Health, and Immunology and Rheumatology (Department of Medicine), Stanford University School of Medicine, USA
| | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Frederick W Miller
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
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22
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Vaccinations in Patients with Rheumatic Disease: Consider Disease and Therapy. Rheum Dis Clin North Am 2022; 48:397-409. [PMID: 35400367 DOI: 10.1016/j.rdc.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patients with rheumatic diseases are susceptible to infections due to their underlying disease states as well as from immunosuppressive medications, highlighting the importance of vaccination, these same factors also pose challenges to vaccine efficacy, safety, and uptake. This article reviews the impact of immunosuppressive therapies and rheumatic disease on vaccine efficacy in this vulnerable patient population as well as discusses best practices.
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23
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Grainger R, Kim AHJ, Conway R, Yazdany J, Robinson PC. COVID-19 in people with rheumatic diseases: risks, outcomes, treatment considerations. Nat Rev Rheumatol 2022; 18:191-204. [PMID: 35217850 PMCID: PMC8874732 DOI: 10.1038/s41584-022-00755-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 02/06/2023]
Abstract
The COVID-19 pandemic has brought challenges for people with rheumatic disease in addition to those faced by the general population, including concerns about higher risks of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and poor outcomes of COVID-19. The data that are now available suggest that rheumatic disease is associated with a small additional risk of SARS-CoV-2 infection, and that outcomes of COVID-19 are primarily influenced by comorbidities and particular disease states or treatments. Despite considerable advances in our knowledge of which therapeutic agents provide benefits in COVID-19, and of what constitutes effective vaccination strategies, the specific considerations that apply to people with rheumatic disease are yet to be definitively addressed. An overview of the most important COVID-19 studies to date that relate to people with rheumatic disease can contribute to our understanding of the clinical-care requirements of this population.
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Affiliation(s)
- Rebecca Grainger
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Alfred H J Kim
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Richard Conway
- Department of Rheumatology, St James's Hospital, Dublin, Ireland
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Philip C Robinson
- University of Queensland School of Clinical Medicine, Faculty of Medicine, Herston, Queensland, Australia.
- Royal Brisbane & Women's Hospital, Metro North Hospital & Health Service, Herston Road, Herston, Queensland, Australia.
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24
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Nakamura Y, Honda D, Takizawa N, Fujita Y. Herpes zoster meningitis in a rheumatoid arthritis patient treated with tofacitinib. BMJ Case Rep 2022; 15:e247276. [PMID: 35236687 PMCID: PMC8895891 DOI: 10.1136/bcr-2021-247276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 12/30/2022] Open
Abstract
A man in his 70s with rheumatoid arthritis presented with seizures and coma and was transferred to our emergency department. Two months prior to admission, he started to take tofacitinib 10 mg/day. On admission, we noted a rash with a blister on the forehead, and herpes zoster was diagnosed. Cerebrospinal fluid examination suggested meningitis. An MRI of the brain showed no abnormality. Based on these findings, he was suspected with herpes zoster meningitis. We discontinued tofacitinib and treated the patient with intravenous acyclovir for 2 weeks. He regained complete consciousness, but right forehead skin lesion, severe vision loss in the right eye and right facial nerve paralysis remained as sequelae. Six weeks after admission, we restarted tofacitinib with oral valaciclovir as antiviral prophylaxis. Two years after admission, we administered Shingrix, an adjuvant recombinant vaccine for herpes zoster, and discontinued oral valaciclovir.
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Affiliation(s)
| | - Daiyu Honda
- Department of Neurology, Nagoya Daiichi Sekijuji Byoin, Nagoya, Aichi, Japan
| | - Naoho Takizawa
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Yoshiro Fujita
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Aichi, Japan
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25
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Herpes Zoster and Vaccination Strategies in Inflammatory Bowel Diseases: A Practical Guide. Clin Gastroenterol Hepatol 2022; 20:481-490. [PMID: 33080353 DOI: 10.1016/j.cgh.2020.10.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023]
Abstract
Herpes zoster is a painful dermatomal cutaneous eruption resulting from reactivation of the latent varicella-zoster virus. Patients with inflammatory bowel diseases have an increased risk of shingles compared with the general population and this risk can be increased with the use of immunosuppressive therapy. Live zoster vaccine and recombinant zoster vaccine have shown efficacy for the prevention of herpes zoster. The recombinant zoster vaccine seems to offer greater efficacy and long-term protection profile compared with the life zoster vaccine. However, their use in clinical practice still is unclear and updated vaccination recommendations are lacking. This review discusses the risk for shingles in patients with inflammatory bowel diseases, available vaccines, and their efficacy and safety profiles. We also provide guidance on who, when, and how to vaccinate for herpes zoster in routine clinical practice among patients with inflammatory bowel diseases.
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26
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Gupta S, Arasaratnam RJ, Solow EB, Bajaj P. A Medical Records Review Study Assessing Safety of Zoster Vaccine Recombinant, Adjuvanted in Patients With Rheumatic Disease. J Clin Rheumatol 2022; 28:e528-e531. [PMID: 34609337 DOI: 10.1097/rhu.0000000000001790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients with rheumatic disease are at increased risk for herpes zoster infection. Because of limited safety data in this population and concerns over vaccine-precipitated flares, there are no guidelines for vaccination with the zoster vaccine recombinant, adjuvanted (ZRA). We evaluated self-reported adverse events (AEs) and disease activity after ZRA administration in adults with rheumatic disease. METHODS In this medical records review study at our large academic center, patients who had received at least 1 dose of ZRA from January 1, 2018 to March 11, 2020 were assessed. Self-reported AEs and disease activity were monitored 3 months after each ZRA administration. Measures of disease activity were reviewed 6 months before ZRA in those who received both doses, or 3 months before ZRA in those who received 1 dose. RESULTS We identified 65 patients, of whom 34 (52.3%) received both doses of ZRA. Four patients (6.2%) self-reported AEs after receiving ZRA, all of which were minor and systemic. Three patients (9.2%) developed a flare after receiving ZRA, compared with 8 (12.3%) who experienced a flare in the baseline period. There was no significant change in flare incidence or disease activity after vaccination. Subgroup analysis of those on biologic and nonbiologic disease-modifying antirheumatic drugs revealed no differences in frequency of postvaccination AEs, flares, or disease activity. CONCLUSIONS In our cohort, disease activity seemed stable when comparing disease markers before and after ZRA administration. In addition, ZRA was well-tolerated with minor AEs. Further studies are needed to guide formal vaccination recommendations.
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Affiliation(s)
- Surbhi Gupta
- From the Department of Rheumatic Diseases, University of California, Los Angeles, Los Angeles, CA
| | | | - E Blair Solow
- Rheumatic Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas TX
| | - Puneet Bajaj
- Rheumatic Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas TX
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27
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Raza S, Acharya S, Howard G, Pattanaik D. Safety of Recombinant Zoster Vaccine in Rheumatology Patients. South Med J 2022; 115:125-128. [PMID: 35118501 DOI: 10.14423/smj.0000000000001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Recombinant zoster vaccine (RZV) is Food and Drug Administration approved for the prevention of herpes zoster (shingles) in adults 50 years old and older. Immunocompromised subjects were excluded from the pivotal vaccine trials. We studied the safety of this vaccine in our university-affiliated rheumatology practice. METHODS This was a single-center, retrospective study focusing on subjects who received RZV during 2018. We collected the demographic data, any self-reported adverse events after vaccination, C-reactive protein, Routine Assessment of Patient Index Data 3 (RAPID3) scores for subjects with rheumatoid arthritis, and available RAPID3 scores for all study subjects before and after the vaccination. RESULTS Comparision of C-reactive protein (n = 40), RAPID3 scores for subjects with rheumatoid arthritis (n = 16), and available RAPID3 scores for all subjects (n = 21) using the paired t test, did not show significant differences before and after the administration of RZV. A total of 6.4% of patients reported adverse events after vaccination. The adverse events were mild and did not lead to hospitalization, end organ damage, or change in treatment plan. CONCLUSIONS The RZV was safe and well tolerated among our study population.
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Affiliation(s)
- Syed Raza
- From the Departments of Rheumatology and Internal Medicine, University of Tennessee Health Science Center, Memphis
| | - Saurav Acharya
- From the Departments of Rheumatology and Internal Medicine, University of Tennessee Health Science Center, Memphis
| | - Gabrielle Howard
- From the Departments of Rheumatology and Internal Medicine, University of Tennessee Health Science Center, Memphis
| | - Debendra Pattanaik
- From the Departments of Rheumatology and Internal Medicine, University of Tennessee Health Science Center, Memphis
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28
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Abstract
Introduction Janus Kinase inhibitors (JAKi) have shown to be highly effective in the treatment of immune-mediated inflammatory diseases. As with all immunomodulatory therapies, careful assessment of any treatment-associated infection risk is essential to inform clinical decision-making. Areas covered We summarize current literature on infection rates among the licensed JAKi using published phase II/III trial results, post-licensing and registry data. Expert opinion licensed JAKi show increased risk of infection across the class compared to placebo, most commonly affecting respiratory and urinary tracts, nasopharynx and skin. This risk is dose-dependent. Risks are similar at licensed JAKi doses to that seen with biologic therapies. The risk is compounded by other risk factors for infection, such as age and steroid co-prescription. Herpes zoster reactivation is more common with JAKi compared to other targeted immune modulation, making screening for varicella exposure and vaccination in appropriate cohorts an advisable strategy. Crucially, these small risk increases must be balanced against the known harms (including infection) of uncontrolled autoimmune disease. JAKi are a safe and potentially transformative treatment when used for appropriately selected patients.
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Affiliation(s)
- Maryam A Adas
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK.,Department of Physiology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Edward Alveyn
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Emma Cook
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Rheumatology, Countess of Chester Hospital Nhs Foundation Trust, Chester, UK
| | - James B Galloway
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Katie Bechman
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
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29
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Liu C, Kieltyka J, Fleischmann R, Gadina M, O’Shea JJ. A Decade of JAK Inhibitors: What Have We Learned and What May Be the Future? Arthritis Rheumatol 2021; 73:2166-2178. [PMID: 34180156 PMCID: PMC8671145 DOI: 10.1002/art.41906] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
The discovery of cytokines and their role in immune and inflammatory disease led to the development of a plethora of targeted biologic therapies. Later, efforts to understand mechanisms of cytokine signal transduction led to the discovery of JAKs, which themselves were quickly identified as therapeutic targets. It has been a decade since the first JAK inhibitors (jakinibs) were approved, and there are now 9 jakinibs approved for the treatment of rheumatic, dermatologic, hematologic, and gastrointestinal indications, along with emergency authorization for COVID-19. In this review, we will summarize relevant discoveries that led to first-generation jakinibs and review their efficacy and safety as demonstrated in pivotal clinical studies. We will discuss the next generation of more selective jakinibs, along with agents that target kinase families beyond JAKs. Finally, we will reflect on both the opportunities and challenges ahead as we enter the second decade of the clinical use of jakinibs.
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Affiliation(s)
- Christine Liu
- Translational Immunology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jacqueline Kieltyka
- Translational Immunology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Roy Fleischmann
- Metroplex Clinical Research Center, University of Texas Southwestern Medical Center
| | - Massimo Gadina
- Translational Immunology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John J. O’Shea
- Molecular Immunology and Inflammation Branch. National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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30
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Bixio R, Bertelle D, Masia M, Pistillo F, Carletto A, Rossini M. Incidence of Disease Flare After BNT162b2 Coronavirus Disease 2019 Vaccination in Patients With Rheumatoid Arthritis in Remission. ACR Open Rheumatol 2021; 3:832-833. [PMID: 34472714 PMCID: PMC8652957 DOI: 10.1002/acr2.11336] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/09/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
| | | | - Marco Masia
- University of Verona Hospital TrustVeronaItaly
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31
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Bonfiglioli KR, da Mota LMH, de Medeiros Ribeiro AC, Kakehasi AM, Laurindo IMM, Giorgi RDN, Duarte ALBP, Reis APMG, Ubirajara E Silva de Souza MPG, Brenol CV, da Rocha Castelar Pinheiro G, de Albuquerque CP, de Moura Castro CH, Pinto GLB, Verztman JF, Muniz LF, Bertolo MB, da Costa Pinto MR, Louzada Júnior P, Cruz VA, Pereira IA, de Freitas MVC, Cruz BA, Paiva E, Monticielo O, Provenza JR, Xavier RM. Recommendations of the Brazilian Society of Rheumatology for the use of JAK inhibitors in the management of rheumatoid arthritis. Adv Rheumatol 2021; 61:70. [PMID: 34819172 DOI: 10.1186/s42358-021-00228-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/05/2021] [Indexed: 11/10/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic and autoimmune systemic inflammatory disease that can cause irreversible joint deformities, with increased morbidity and mortality and a significant impact on the quality of life of the affected individual. The main objective of RA treatment is to achieve sustained clinical remission or low disease activity. However, up to 40% of patients do not respond to available treatments, including bDMARDs. New therapeutic targets for RA are emerging, such as Janus kinases (JAKs). These are essential for intracellular signaling (via JAK-STAT) in response to many cytokines involved in RA immunopathogenesis. JAK inhibitors (JAKi) have established themselves as a highly effective treatment, gaining increasing space in the therapeutic arsenal for the treatment of RA. The current recommendations aim to present a review of the main aspects related to the efficacy and safety of JAKis in RA patients, and to update the recommendations and treatment algorithm proposed by the Brazilian Society of Rheumatology in 2017.
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Affiliation(s)
- Karina Rossi Bonfiglioli
- Disciplina Reumatologia do Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP), Av. Dr. Arnaldo, 455 - 3° andar - Reumatologia, São Paulo, SP, CEP, 01246-903, Brasil.
| | | | - Ana Cristina de Medeiros Ribeiro
- Disciplina Reumatologia do Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP), Av. Dr. Arnaldo, 455 - 3° andar - Reumatologia, São Paulo, SP, CEP, 01246-903, Brasil
| | - Adriana Maria Kakehasi
- Serviço de Reumatologia, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | | | - Rina Dalva Neubarth Giorgi
- Serviço de Reumatologia, Hospital do Servidor Público Estadual de São Paulo (HSPE-IAMSPE), São Paulo, Brazil
| | | | | | | | - Claiton Viegas Brenol
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre, Brazil
| | | | | | | | | | | | | | - Manoel Barros Bertolo
- Disciplina de Reumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brazil
| | | | - Paulo Louzada Júnior
- Disciplina de Reumatologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP-RP), Ribeirão Preto, Brazil
| | - Vitor Alves Cruz
- Disciplina de Reumatologia, Faculdade de Medicina, Universidade Federal de Goiás, Goiânia, Brazil
| | - Ivanio Alves Pereira
- Serviço de Reumatologia do Hospital Universitário, Universidade Federal de Santa Catarina-UFSC, Florianópolis, Brazil
| | | | | | - Eduardo Paiva
- Disciplina de Reumatologia, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Odirlei Monticielo
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre, Brazil
| | - José Roberto Provenza
- Disciplina de Reumatologia da Pontificia, Universidade Católica de Campinas, PUC-Campinas, Campinas, Brazil
| | - Ricardo Machado Xavier
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre, Brazil
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Curtis JR, Cofield SS, Bridges SL, Bassler J, Deodhar A, Ford TL, Huffstutter J, Jankeel A, Kivitz A, Kamal S, Lindsey S, Messaoudi I, Mendoza N, Michaud K, Mikuls TR, Ridley D, Shergy W, Siegel SAR, Winthrop KL. The Safety and Immunologic Effectiveness of the Live Varicella-Zoster Vaccine in Patients Receiving Tumor Necrosis Factor Inhibitor Therapy : A Randomized Controlled Trial. Ann Intern Med 2021; 174:1510-1518. [PMID: 34570596 DOI: 10.7326/m20-6928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The safety and effectiveness of live virus vaccines, such as the varicella-zoster vaccine, are unknown in patients with inflammatory diseases receiving immunomodulatory therapy such as tumor necrosis factor inhibitors (TNFis). OBJECTIVE To evaluate the safety and immunogenicity of the live attenuated zoster vaccine (ZVL) in patients receiving TNFis. DESIGN Randomized, blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT02538341). SETTING Academic and community-based rheumatology, gastroenterology, and dermatology practices. PATIENTS Adults aged 50 years or older receiving TNFis for any indication. INTERVENTION Random assignment to ZVL versus placebo. MEASUREMENTS Glycoprotein enzyme-linked immunosorbent assay (gpELISA) and enzyme-linked immunosorbent spot (ELISpot) from serum and peripheral blood mononuclear cells measured at baseline and 6 weeks after vaccination. Suspected varicella infection or herpes zoster was clinically assessed using digital photographs and polymerase chain reaction on vesicular fluid. RESULTS Between March 2015 and December 2018, 617 participants were randomly assigned in a 1:1 ratio to receive ZVL (n = 310) or placebo (n = 307) at 33 centers. Mean age was 62.7 years (SD, 7.5); 66.1% of participants were female, 90% were White, 8.2% were Black, and 5.9% were Hispanic. The most common TNFi indications were rheumatoid arthritis (57.6%) and psoriatic arthritis (24.1%); TNFi medications were adalimumab (32.7%), infliximab (31.3%), etanercept (21.2%), golimumab (9.1%), and certolizumab (5.7%). Concomitant therapies included methotrexate (48.0%) and oral glucocorticoids (10.5%). Through week 6, no cases of confirmed varicella infection were found; cumulative incidence of varicella infection or shingles was 0.0% (95% CI, 0.0% to 1.2%). At 6 weeks, compared with baseline, the mean increases in geometric mean fold rise as measured by gpELISA and ELISpot were 1.33 percentage points (CI, 1.17 to 1.51 percentage points) and 1.39 percentage points (CI, 1.07 to 1.82 percentage points), respectively. LIMITATION Potentially limited generalizability to patients receiving other types of immunomodulators. CONCLUSION This trial informs safety concerns related to use of live virus vaccines in patients receiving biologics. PRIMARY FUNDING SOURCE The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American College of Rheumatology.
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Affiliation(s)
- Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama (J.R.C., S.K.)
| | - Stacey S Cofield
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, Alabama (S.S.C., J.B.)
| | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York (S.L.B.)
| | - John Bassler
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, Alabama (S.S.C., J.B.)
| | - Atul Deodhar
- Oregon Health & Science University, Portland, Oregon (A.D., S.A.S., K.L.W.)
| | - Theresa L Ford
- North Georgia Rheumatology Group, Lawrenceville, Georgia (T.L.F.)
| | | | - Allen Jankeel
- University of California, Irvine, Irvine, California (A.J., I.M., N.M.)
| | - Alan Kivitz
- Altoona Center for Clinical Research, Duncansville, Pennsylvania (A.K.)
| | - Shaila Kamal
- Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama (J.R.C., S.K.)
| | | | - Ilhem Messaoudi
- University of California, Irvine, Irvine, California (A.J., I.M., N.M.)
| | - Norma Mendoza
- University of California, Irvine, Irvine, California (A.J., I.M., N.M.)
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, Nebraska, and FORWARD-The National Databank for Rheumatic Diseases, Wichita, Kansas (K.M.)
| | - Ted R Mikuls
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska (T.R.M.)
| | - David Ridley
- St. Paul Rheumatology, P.A., Eagan, Minnesota (D.R.)
| | - William Shergy
- RANA - Rheumatology Associates of North Alabama, Huntsville, Alabama (W.S.)
| | - Sarah A R Siegel
- Oregon Health & Science University, Portland, Oregon (A.D., S.A.S., K.L.W.)
| | - Kevin L Winthrop
- Oregon Health & Science University, Portland, Oregon (A.D., S.A.S., K.L.W.)
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Friedman MA, Curtis JR, Winthrop KL. Impact of disease-modifying antirheumatic drugs on vaccine immunogenicity in patients with inflammatory rheumatic and musculoskeletal diseases. Ann Rheum Dis 2021; 80:1255-1265. [PMID: 34493491 DOI: 10.1136/annrheumdis-2021-221244] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/25/2021] [Indexed: 12/14/2022]
Abstract
Patients with rheumatic diseases are at increased risk of infectious complications; vaccinations are a critical component of their care. Disease-modifying antirheumatic drugs may reduce the immunogenicity of common vaccines. We will review here available data regarding the effect of these medications on influenza, pneumococcal, herpes zoster, SARS-CoV-2, hepatitis B, human papilloma virus and yellow fever vaccines. Rituximab has the most substantial impact on vaccine immunogenicity, which is most profound when vaccinations are given at shorter intervals after rituximab dosing. Methotrexate has less substantial effect but appears to adversely impact most vaccine immunogenicity. Abatacept likely decrease vaccine immunogenicity, although these studies are limited by the lack of adequate control groups. Janus kinase and tumour necrosis factor inhibitors decrease absolute antibody titres for many vaccines, but do not seem to significantly impact the proportions of patients achieving seroprotection. Other biologics (interleukin-6R (IL-6R), IL-12/IL-23 and IL-17 inhibitors) have little observed impact on vaccine immunogenicity. Data regarding the effect of these medications on the SARS-CoV-2 vaccine immunogenicity are just now emerging, and early glimpses appear similar to our experience with other vaccines. In this review, we summarise the most recent data regarding vaccine response and efficacy in this setting, particularly in light of current vaccination recommendations for immunocompromised patients.
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Affiliation(s)
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Department of Medicine, Birmingham, Alabama, USA
| | - Kevin L Winthrop
- Medicine, Oregon Health & Science University, Portland, Oregon, USA.,School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
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Ebina K. Drug efficacy and safety of biologics and Janus kinase inhibitors in elderly patients with rheumatoid arthritis. Mod Rheumatol 2021; 32:256-262. [PMID: 34894239 DOI: 10.1093/mr/roab003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/21/2021] [Accepted: 05/24/2021] [Indexed: 11/14/2022]
Abstract
Elderly patients with rheumatoid arthritis (RA) are frequently associated with higher disease activity and impaired physical function, although they show intolerance for conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), such as methotrexate, because of their comorbidities. However, the present treatment recommendation based on randomized controlled trials is not distinguished by age or comorbidities. Therefore, this review aimed to investigate the efficacy and safety of biological DMARDs (bDMARDs) and Janus kinase inhibitors (JAKi) in elderly patients. Present bDMARDs, including tumor necrosis factor inhibitors (TNFi), cytotoxic T lymphocyte-associated antigen-4-immunoglobulin (abatacept), interleukin (IL)-6 receptor antibody (tocilizumab and salirumab), and anti-CD20 antibody (rituximab), may be similarly or slightly less effective or safe in elderly patients compared with younger patients. Oral glucocorticoid use, prolonged disease duration, and very old patients appear to be associated with an increased risk of adverse events, such as serious infection. Some recent cohort studies demonstrated that non-TNFi showed better retention than TNFi in elderly patients. Both TNFi and non-TNFi agents may not strongly influence the risk of adverse events such as cardiovascular events and malignancy in elderly patients. Regarding JAKi, the efficacy appears to be similar, although the safety (particularly for serious infections, including herpes zoster) may be attenuated by aging.
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Affiliation(s)
- Kosuke Ebina
- Department of Musculoskeletal Regenerative Medicine, Osaka University, Graduate School of Medicine, Osaka 565-0871, Japan
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35
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Updates in the Treatment of Rheumatoid Arthritis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00173-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Patients with rheumatic diseases are susceptible to infections due to their underlying disease states as well as from immunosuppressive medications, highlighting the importance of vaccination, these same factors also pose challenges to vaccine efficacy, safety, and uptake. This article reviews the impact of immunosuppressive therapies and rheumatic disease on vaccine efficacy in this vulnerable patient population as well as discusses best practices.
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Affiliation(s)
- Cassandra Calabrese
- Department of Rheumatologic & Immunologic Disease, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A50, Cleveland, OH 44195, USA.
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Lenfant T, Jin Y, Kirchner E, Hajj-Ali RA, Calabrese LH, Calabrese C. Safety of Recombinant Zoster Vaccine: a Retrospective Study of 622 Rheumatology Patients. Rheumatology (Oxford) 2021; 60:5149-5157. [PMID: 33560302 DOI: 10.1093/rheumatology/keab139] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/18/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To provide insight into the safety of Recombinant Zoster Vaccine (RZV) in patients with Immune-Mediated Inflammatory Diseases (IMID). METHODS Patients who received RZV in a single center Rheumatology Department were retrospectively included. An IMID flare was defined as a) a documentation of flare in the office notes or patient portal communication or b) new prednisone prescription, in the 12 weeks after each dose. RESULTS Six-hundred twenty-two patients were included (67% female, median age 67 years), 8.5% of them experienced AEs and HZ incidence was 0.6% after median follow-up of 36 weeks. Of 359 IMID patients: 88 had RA (25%), 50 vasculitis (14%), 29 PMR (8%). At vaccination, 35% were on glucocorticoids (GC). Fifty-nine patients (16%) experienced a flare, 18 flares occurred in temporal relation to a treatment change (31%). RA patients had the highest flare rate (n = 21, 24%), 25% of patients who flared required adjustment of immunosuppression. In a multivariate analysis, use of GC at time of vaccination was associated with flare after vaccination (OR 2.31 [1.3-4.1], p = 0.004). A time-to-flare survival analysis (Cox-model) showed that GC was a significant predictor of IMID flare after first RZV dose (HR 2.4 [1.3-4.5], p = 0.0039) and that a flare after the first dose was associated with flaring after the second RZV dose (HR 3.9 [1.7-9], p = 0.0015). CONCLUSION RZV administration in patients with IMIDs was generally well-tolerated, though mild flares were not uncommon in the first 12 weeks after vaccination. These data may provide useful information for patient education when considering RZV administration.
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Affiliation(s)
- Tiphaine Lenfant
- Department of Rheumatologic and Immunologic Diseases, Orthopedic & Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Department of Internal Medicine, Hôpital européen Georges Pomidou, AP-HP, Université de Paris, Paris, France
| | - Yuxuan Jin
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Elizabeth Kirchner
- Department of Rheumatologic and Immunologic Diseases, Orthopedic & Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rula A Hajj-Ali
- Department of Rheumatologic and Immunologic Diseases, Orthopedic & Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Leonard H Calabrese
- Department of Rheumatologic and Immunologic Diseases, Orthopedic & Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Cassandra Calabrese
- Department of Rheumatologic and Immunologic Diseases, Orthopedic & Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
In the case of reduced cellular immunity the previously dormant varicella zoster virus (VZV) causes the characteristic belt-shaped vesicular exanthema of herpes zoster. The initial clinical symptoms of herpes zoster are often non-specific and may lead to initial misdiagnosis. A common complication of herpes zoster is postherpetic neuralgia (PHN) but secondary hematogenic dissemination is only rarely observed. In addition to general factors, such as advanced age and female gender, inflammatory rheumatic diseases and their immunosuppressive treatment are important risk factors for the occurrence of herpes zoster. Antiviral therapy initiated in the first 72 h after the onset of exanthema reduces acute symptoms and the risk of complications. The subunit inactivated vaccine, which has been available since 2018, is highly effective and relatively well-tolerated but randomized controlled trials in patients with drug-induced immunosuppression for inflammatory rheumatic diseases are still pending.
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Affiliation(s)
- Boris Ehrenstein
- Klinik und Poliklinik für Rheumatologie/Klinische Immunologie, Asklepios Klinikum Bad Abbach, 93077, Bad Abbach, Deutschland.
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