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Ammitzbøll C, Thomsen MK, Bartels LE, Hansen CB, Hermansen MLF, Hänel M, Klose-Jensen R, Larsen ML, Lauritsen MO, Mistegaard CE, Mikkelsen S, Olesen JBM, Næser EU, Nielsen MA, Erikstrup C, Garred P, Hauge EM, Troldborg A. COVID-19 Vaccination Before Initiating Rituximab Treatment Induces Strong Serological Response in Autoimmune Rheumatic Disease, Reducing Post-Pandemic Concerns About the Impact of Rituximab. ACR Open Rheumatol 2024. [PMID: 38923834 DOI: 10.1002/acr2.11681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/06/2024] [Accepted: 04/12/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE Rituximab (RTX)-treated patients exhibit suboptimal responses to COVID-19 vaccines. However, existing research primarily involves patients already receiving RTX when vaccines were introduced, failing to account for the current landscape where patients are vaccinated before initiating RTX. Our objective was to compare the serological response to COVID-19 vaccines in patients vaccinated before or after RTX initiation. METHODS We included 254 RTX-treated patients with autoimmune inflammatory rheumatic diseases (AIIRDs) and 113 blood donors (BDs) in a retrospective, observational cohort study. Patients were categorized based on the timing of RTX treatment relative to primary COVID-19 vaccination. Serological vaccine responses were assessed using three immunoassays, and logistic regression analysis was used to identify predictors of serological response. RESULTS Patients vaccinated before initiating RTX treatment had significantly higher seroconversion rates of SARS-CoV-2 immunoglobulin G (87%) and neutralizing antibodies (91%) compared with those receiving RTX before and after vaccination (n = 132) (61% and 65%, respectively). In the logistic regression analysis, a positive serological response was associated with the number of vaccines administered >9 months after the last RTX treatment. Patients receiving the highest number of vaccines with >9 months after RTX showed a response comparable to that of the BDs. CONCLUSION Vaccinating before RTX initiation yields a robust serological response in patients with AIIRDs. Furthermore, we highlight the reversibility of antibody impairment after RTX treatment cessation, provided that adequate vaccinations occur within a minimum of 9 months after RTX. Our findings offer essential insights for clinical decision-making regarding COVID-19 vaccination and RTX treatment, alleviating concerns about future RTX use.
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Affiliation(s)
| | | | | | - Cecilie Bo Hansen
- Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Mathias Hänel
- Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | | | - Mads Lamm Larsen
- Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | | | | | | | | | | | | | | | - Peter Garred
- Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Anne Troldborg
- Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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2
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Patel NJ, Wang X, Lin M, Kowalski EN, Cook CE, Vanni KMM, Guzzo K, Qian G, Bade KJ, Saavedra A, Venkat R, Srivatsan S, Williams ZK, Hanberg JS, Kawano Y, Schiff AE, Sparks JA, Wallace ZS. Factors Associated With an Electronic Health Record-Based Definition of Postacute Sequelae of COVID-19 in Patients With Systemic Autoimmune Rheumatic Disease. J Rheumatol 2024; 51:529-537. [PMID: 38428964 PMCID: PMC11065568 DOI: 10.3899/jrheum.2023-1092] [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] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Many individuals with rheumatic disease are at higher risk for severe acute coronavirus disease 2019 (COVID-19). We aimed to evaluate risk factors for postacute sequelae of COVID-19 (PASC) using an electronic health record (EHR)-based definition. METHODS We identified patients with prevalent rheumatic diseases and COVID-19 within the Mass General Brigham healthcare system. PASC was defined by the International Classification of Diseases, 10th revision (ICD-10) codes, relevant labs, vital signs, and medications at least 30 days following the first COVID-19 infection. Patients were followed until the earliest of incident PASC, repeat COVID-19 infection, 1 year of follow-up, death, or February 19, 2023. We used multivariable Cox regression to estimate the association of baseline characteristics with PASC risk. RESULTS Among 2459 patients (76.37% female, mean age 57.4 years), the most common incident PASC manifestations were cough (14.56%), dyspnea (12.36%), constipation (11.39%), and fatigue (10.70%). Serious manifestations including acute coronary disease (4.43%), thromboembolism (3.09%), hypoxemia (3.09%), stroke (1.75%), and myocarditis (0.12%) were rare. The Delta wave (adjusted hazard ratio [aHR] 0.63, 95% CI 0.49-0.82) and Omicron era (aHR 0.50, 95% CI 0.41-0.62) were associated with lower risk of PASC than the early pandemic period (March 2020-June 2021). Age, obesity, comorbidity burden, race, and hospitalization for acute COVID-19 infection were associated with greater risk of PASC. Glucocorticoid (GC) use (aHR 1.19, 95% CI 1.05-1.34 compared to no use) was associated with greater risk of PASC. CONCLUSION Among patients with rheumatic diseases, following their first COVID-19 infection, we found a decreased risk of PASC over calendar time using an EHR-based definition. Aside from GCs, no specific immunomodulatory medications were associated with increased risk, and risk factors were otherwise similar to those seen in the general population.
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Affiliation(s)
- Naomi J Patel
- N.J. Patel, MD, MPH, Z.S. Wallace, MD, MSc, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Harvard Medical School, and Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital
| | - Xiaosong Wang
- X. Wang, MS, E.N. Kowalski, BS, K.M.M. Vanni, BA, G. Qian, BA&Sc, K.J. Bade, BS, A. Saavedra, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Miao Lin
- M. Lin, MS, C.E. Cook, MPH, K. Guzzo, BA, S. Srivatsan, BS, Z.K. Williams, BS, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital
| | - Emily N Kowalski
- X. Wang, MS, E.N. Kowalski, BS, K.M.M. Vanni, BA, G. Qian, BA&Sc, K.J. Bade, BS, A. Saavedra, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Claire E Cook
- M. Lin, MS, C.E. Cook, MPH, K. Guzzo, BA, S. Srivatsan, BS, Z.K. Williams, BS, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital
| | - Kathleen M M Vanni
- X. Wang, MS, E.N. Kowalski, BS, K.M.M. Vanni, BA, G. Qian, BA&Sc, K.J. Bade, BS, A. Saavedra, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Krishan Guzzo
- M. Lin, MS, C.E. Cook, MPH, K. Guzzo, BA, S. Srivatsan, BS, Z.K. Williams, BS, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital
| | - Grace Qian
- X. Wang, MS, E.N. Kowalski, BS, K.M.M. Vanni, BA, G. Qian, BA&Sc, K.J. Bade, BS, A. Saavedra, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Katarina J Bade
- X. Wang, MS, E.N. Kowalski, BS, K.M.M. Vanni, BA, G. Qian, BA&Sc, K.J. Bade, BS, A. Saavedra, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Alene Saavedra
- X. Wang, MS, E.N. Kowalski, BS, K.M.M. Vanni, BA, G. Qian, BA&Sc, K.J. Bade, BS, A. Saavedra, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | | | - Shruthi Srivatsan
- M. Lin, MS, C.E. Cook, MPH, K. Guzzo, BA, S. Srivatsan, BS, Z.K. Williams, BS, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital
| | - Zachary K Williams
- M. Lin, MS, C.E. Cook, MPH, K. Guzzo, BA, S. Srivatsan, BS, Z.K. Williams, BS, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital
| | - Jennifer S Hanberg
- J.S. Hanberg, MD, Y. Kawano, MD, J.A. Sparks, MD, MMSc, Harvard Medical School, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Yumeko Kawano
- J.S. Hanberg, MD, Y. Kawano, MD, J.A. Sparks, MD, MMSc, Harvard Medical School, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Abigail E Schiff
- A.E. Schiff, MD, PhD, Harvard Medical School, and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey A Sparks
- J.S. Hanberg, MD, Y. Kawano, MD, J.A. Sparks, MD, MMSc, Harvard Medical School, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Zachary S Wallace
- N.J. Patel, MD, MPH, Z.S. Wallace, MD, MSc, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Harvard Medical School, and Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital;
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3
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Kawano Y, Wang X, Patel NJ, Qian G, Kowalski E, Bade KJ, Vanni KMM, Jonsson AH, Williams ZK, Cook CE, Srivatsan S, Wallace ZS, Sparks JA. Breakthrough COVID-19 After Tixagevimab/Cilgavimab Among Patients With Systemic Autoimmune Rheumatic Diseases. J Rheumatol 2024; 51:305-312. [PMID: 37839812 PMCID: PMC10925916 DOI: 10.3899/jrheum.2023-0742] [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] [Accepted: 09/30/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE To determine the incidence and baseline factors associated with breakthrough coronavirus disease 2019 (COVID-19) after preexposure prophylaxis (PrEP) with tixagevimab/cilgavimab among patients with systemic autoimmune rheumatic diseases (SARDs). METHODS We performed a retrospective cohort study among patients with SARDs who received tixagevimab/cilgavimab between January 2, 2022, and November 16, 2022. The primary outcome was breakthrough COVID-19 after tixagevimab/cilgavimab. We performed multivariable Cox regression models adjusted for baseline factors to identify risk factors for breakthrough COVID-19. RESULTS We identified 444 patients with SARDs who received tixagevimab/cilgavimab (mean age 62.0 years, 78.2% female). There were 83 (18.7%) breakthrough COVID-19 cases (incidence rate 31.5/1000 person-months, 95% CI 24.70-38.24), 7 (1.6%) hospitalizations, and 1 (0.2%) death. Older age was inversely associated with breakthrough COVID-19 (adjusted hazard ratio [aHR] 0.86/10 years, 95% CI 0.75-0.99). Higher baseline spike antibody levels were associated with lower risk of breakthrough COVID-19 (aHR 0.42, 95% CI 0.18-0.99 for spike antibody levels > 200 vs < 0.4 units). CD20 inhibitor users had a similar risk of breakthrough COVID-19 (aHR 1.05, 95% CI 0.44-2.49) compared to conventional synthetic disease-modifying antirheumatic drug (DMARD) users. CONCLUSION We found that patients with SARDs had frequent breakthrough COVID-19, but the proportion experiencing severe COVID-19 was low. DMARD type, including CD20 inhibitors, did not significantly affect risk of breakthrough COVID-19. Evidence of prior humoral immunity was protective against breakthrough infection, highlighting the continued need for a multimodal approach to prevent severe COVID-19 as novel PrEP therapies are being developed.
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Affiliation(s)
- Yumeko Kawano
- Y. Kawano, MD, A.H. Jonsson, MD, PhD, J.A. Sparks, MD, MMSc, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, and Harvard Medical School
| | - Xiaosong Wang
- X. Wang, MS, G. Qian, BA&Sc, E. Kowalski, BS, K.J. Bade, BS, K.M.M. Vanni, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Naomi J Patel
- N.J. Patel, MD, Z.S. Wallace, MD, MSc, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Harvard Medical School
| | - Grace Qian
- X. Wang, MS, G. Qian, BA&Sc, E. Kowalski, BS, K.J. Bade, BS, K.M.M. Vanni, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Emily Kowalski
- X. Wang, MS, G. Qian, BA&Sc, E. Kowalski, BS, K.J. Bade, BS, K.M.M. Vanni, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Katarina J Bade
- X. Wang, MS, G. Qian, BA&Sc, E. Kowalski, BS, K.J. Bade, BS, K.M.M. Vanni, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - Kathleen M M Vanni
- X. Wang, MS, G. Qian, BA&Sc, E. Kowalski, BS, K.J. Bade, BS, K.M.M. Vanni, BA, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital
| | - A Helena Jonsson
- Y. Kawano, MD, A.H. Jonsson, MD, PhD, J.A. Sparks, MD, MMSc, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, and Harvard Medical School
| | - Zachary K Williams
- Z.K. Williams, BA, C.E. Cook, MPH, S. Srivatsan, BA, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Claire E Cook
- Z.K. Williams, BA, C.E. Cook, MPH, S. Srivatsan, BA, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shruthi Srivatsan
- Z.K. Williams, BA, C.E. Cook, MPH, S. Srivatsan, BA, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zachary S Wallace
- N.J. Patel, MD, Z.S. Wallace, MD, MSc, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, and Harvard Medical School
| | - Jeffrey A Sparks
- Y. Kawano, MD, A.H. Jonsson, MD, PhD, J.A. Sparks, MD, MMSc, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, and Harvard Medical School;
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4
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Gentile S, Sullivan LR, Brooks H, Simeunovic G. A Descriptive, Retrospective Analysis of COVID-19 Passive Antibody Therapy and Its Effects on Morbidity and Mortality in Patients Receiving B-Cell-Depleting Therapies. Diseases 2024; 12:33. [PMID: 38391780 PMCID: PMC10887790 DOI: 10.3390/diseases12020033] [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: 12/10/2023] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024] Open
Abstract
Patients receiving B-cell-depleting therapies (BCDT) are at an increased risk for severe COVID-19. Passive antibody therapy (PAT), including COVID-19 convalescent plasma (CCP) and monoclonal antibodies (mAb), may be an effective treatment in this population. Real-world data on PAT effectiveness are limited. To evaluate response to PAT measured through 90-day all-cause morbidity and mortality, we performed a retrospective review of patients who contracted COVID-19 within a year from the last BCDT. From 64 included patients, the majority were Caucasians (95%), female (56%), vaccinated (67%), treated outpatients (64%), with multiple comorbidities. Examined BCDT were rituximab (55%), obinutuzumab (33%), ocrelizumab (11%) and ofatumumab (1%), used for underlying hematological malignancy (HEM) (40%), multiple sclerosis (34%), and rheumatoid arthritis (16%). Of seven deceased patients, three died from COVID-19. All three were elderly males with multiple comorbidities, treated inpatient for severe COVID-19. Four of 41 patients treated as outpatients were hospitalized for non-COVID-19-related reasons. All deceased and hospitalized patients had an underlying HEM. All but one were on rituximab. PAT may be an effective treatment for patients receiving BCDT, especially if given early for non-severe disease. Patients with underlying HEM may be at increased risk for severe disease compared with others receiving the same BCDT.
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Affiliation(s)
- Sonia Gentile
- Department of Internal Medicine and Pediatrics, Corewell Health, Grand Rapids, MI 49503, USA
- College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
| | - Liam R Sullivan
- College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
- Department of Infectious Disease, Corewell Health, Grand Rapids, MI 49503, USA
| | - Heather Brooks
- Office of Research and Education, Corewell Health, Grand Rapids, MI 49503, USA
| | - Gordana Simeunovic
- College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
- Department of Infectious Disease, Corewell Health, Grand Rapids, MI 49503, USA
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5
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Kowalski EN, Wang X, Patel NJ, Kawano Y, Cook CE, Vanni KMM, Qian G, Bade KJ, Srivatsan S, Williams ZK, Wallace ZS, Sparks JA. Risk factors and outcomes for repeat COVID-19 infection among patients with systemic autoimmune rheumatic diseases: A case-control study. Semin Arthritis Rheum 2023; 63:152286. [PMID: 37913612 PMCID: PMC10842150 DOI: 10.1016/j.semarthrit.2023.152286] [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: 08/02/2023] [Revised: 10/12/2023] [Accepted: 10/20/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To investigate risk factors and outcomes of repeat COVID-19 infections among patients with systemic autoimmune rheumatic diseases (SARDs). METHODS We performed a case-control study investigating repeat COVID-19 infection within the Mass General Brigham Health Care System. We systematically identified all SARD patients with confirmed COVID-19 (15/Mar/2020 to 17/Oct/2022). Cases had confirmed repeat COVID-19 infections >60 days apart (index date: repeat COVID-19 date). Controls were matched to cases (up to 3:1) by calendar date of first infection and duration between first COVID-19 infection and index dates. We collected demographics, lifestyle, comorbidities, SARD features, and COVID-19 characteristics at initial infection and index date by medical record review. We used conditional logistic regression to identify associations with repeat COVID-19 infection, adjusting for potential confounders. We described the severity of repeat COVID-19 infection among cases. RESULTS Among 2203 SARD patients with COVID-19, we identified 76 cases with repeat COVID-19 infection (80.3 % female) and matched to 207 matched controls (77.8 % female) with no repeat infection. At first infection, cases were younger (mean 49.5 vs. 60.3 years, p < 0.0001), less likely to have hypertension (32.9 % vs. 45.9 %, p = 0.050), and less likely to have been hospitalized for COVID-19 (13.2 % vs. 24.6 %, p = 0.037) than controls. At index date, cases were more likely than controls to be rituximab users (18.4 % vs. 6.3 %, p = 0.0021). In the multivariable model, younger age (OR 0.67 per 10 years, 95 %CI 0.54-0.82), rituximab use vs. non-use (OR 3.38, 95 %CI 1.26-9.08), and methotrexate use vs. non-use (OR 2.24, 95 %CI 1.08-4.61) were each associated with repeat COVID-19 infection. Among those with repeat COVID-19 infection, 5/76 (6.6 %) were hospitalized and there were no deaths. CONCLUSION Younger age, rituximab, and methotrexate were each associated with repeat COVID-19 infection risk among patients with SARDs. Reassuringly, there were no deaths, and the hospitalization rate was low among those with repeat COVID-19 infection.
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Affiliation(s)
- Emily N Kowalski
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Xiaosong Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Harvard Medical School, Boston, MA, USA
| | - Yumeko Kawano
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA; Harvard Medical School, Boston, MA, USA
| | - Claire E Cook
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Kathleen M M Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Grace Qian
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Katarina J Bade
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Shruthi Srivatsan
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Zachary K Williams
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Harvard Medical School, Boston, MA, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA; Harvard Medical School, Boston, MA, USA.
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Kow CS, Ramachandram DS, Hasan SS, Thiruchelvam K. Systematic review and meta-analysis of anti-CD20 treatments in patients with COVID-19: an assessment of severe illness and mortality outcomes. Inflammopharmacology 2023; 31:3339-3355. [PMID: 37804462 DOI: 10.1007/s10787-023-01349-z] [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: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND The use of anti-CD20 monoclonal antibodies, such as rituximab and ocrelizumab, has emerged as a matter of concern, in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE We aimed to summarize the overall evidence on the pre-admission/pre-diagnosis use of anti-CD20 among patients with COVID-19 with regards to mortality and severe illness outcomes. METHODS A systematic literature search with no language restriction was performed in electronic databases, including PubMed, Google Scholar, Scopus, and preprint servers (medRxiv, Research Square, SSRN), to identify eligible studies published up to June 13, 2023. The outcomes of interest were the development of severe illness and all-cause mortality. A random-effects model was used to estimate the pooled odds ratio for outcomes of interest using anti-CD20 monoclonal antibodies relative to non-use of anti-CD20 monoclonal antibodies, at 95% confidence intervals. RESULTS Our systematic review and meta-analysis revealed significantly increased odds for development of severe illness (pooled odds ratio 2.95; 95% confidence interval 2.30, 3.78; n = 534,349) and significantly increased odds for mortality (pooled odds ratio 2.14; 95% confidence interval 1.37, 3.35; n = 333,462) with the use of anti-CD20 monoclonal antibodies, relative to non-use of anti-CD20 monoclonal antibodies, in patients with COVID-19. CONCLUSION Healthcare practitioners should exercise caution when prescribing these anti-CD20 monoclonal antibodies during the COVID-19 pandemic to patients who are indicated for these agents, particularly those with underlying conditions like multiple sclerosis or rheumatoid arthritis.
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Affiliation(s)
- Chia Siang Kow
- School of Pharmacy, International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia
| | | | - Syed Shahzad Hasan
- School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| | - Kaeshaelya Thiruchelvam
- School of Pharmacy, International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia.
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7
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Ginman B, Pahnke S, Freyhult E, Hoffman T, Kolstad L, Rönnberg B, Lundkvist Å, Hamberg Levedahl K, Enblad G, Glimelius I. Strict self-isolation did not protect Swedish cancer patients on active treatment from the risk of becoming seropositive for SARS-CoV-2. Acta Oncol 2023; 62:1707-1715. [PMID: 37729083 DOI: 10.1080/0284186x.2023.2257873] [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: 07/03/2023] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Swedish recommendations to reduce the risk of COVID-19 relied on each citizen's own sense of responsibility rather than mandatory lockdowns. We studied how COVID-19-related self-isolation and anxiety correlated to SARS-CoV-2 seropositivity and PCR-positivity in patients with active cancer treatment. METHODS In a longitudinal cohort study at Uppsala University Hospital patients and cancer personnel were included between April 1st 2020 to August 1st 2020. Serological testing for SARS-CoV-2 was done every 8-12-weeks until 30 March 2021. Patients completed a survey at inclusion regarding self-reported COVID-19-related anxiety and self-isolation. RESULTS A total of 622 patients [n = 475 with solid malignancies (SM), n = 147 with haematological malignancies (HM)], and 358 healthcare personnel were included. The seropositivity rate was lower for patients than for personnel; 10.5% for SM patients, 6.8% for HM patients, and 16.2% for personnel (p = 0.005). Strict adherence to self-isolation guidelines was reported by 54% of patients but was not associated with a lower risk of becoming seropositive [OR = 1.4 (0.8-2.5), p = 0.2]. High anxiety was expressed by 32% of patients, more often by SM patients than HM patients (34% vs 25% [OR = 1.6 (1.1-2.5, p = 0.03)]). Female gender [OR = 3.5 (2.4-5.2), p < 0.001] and being born outside of Europe [OR = 2.9 (1.4-6.4), p = 0.007] were both associated with high anxiety. Patients reporting high anxiety became seropositive to a similar degree as those with low anxiety [OR = 0.7 (0.3-1.2), p = 0.2]. HM patients with PCR-positive COVID-19 were more likely than SM patients to require oxygen therapy, including non-invasive ventilation/intubation (69% vs. 26%, p = 0.005). CONCLUSION For Swedish patients on active cancer treatment, high self-assessed COVID-19-related anxiety or strict adherence to self-isolation guidelines were not associated with a lower risk of COVID-19. Patients with HM were less likely to develop serological antibody response after COVID-19 and were more likely to require advanced hospital care, but expressed less COVID-19-related anxiety than patients with SM.
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Affiliation(s)
- Beatrice Ginman
- Department of Immunology, Genetics and Pathology, Cancer Precision Medicine, Uppsala University, Sweden
| | - Simon Pahnke
- Department of Immunology, Genetics and Pathology, Cancer Precision Medicine, Uppsala University, Sweden
| | - Eva Freyhult
- Department of Cell and Molecular Biology, National Bioinformatics Infrastructure Sweden, Science for Life Laboratory, Uppsala, Sweden
| | - Tove Hoffman
- Department of Medical Biochemistry and Microbiology, Zoonosis Science Center, Uppsala University, Uppsala, Sweden
| | - Linda Kolstad
- Department of Medical Biochemistry and Microbiology, Zoonosis Science Center, Uppsala University, Uppsala, Sweden
| | - Bengt Rönnberg
- Department of Medical Biochemistry and Microbiology, Zoonosis Science Center, Uppsala University, Uppsala, Sweden
| | - Åke Lundkvist
- Department of Medical Biochemistry and Microbiology, Zoonosis Science Center, Uppsala University, Uppsala, Sweden
| | | | - Gunilla Enblad
- Department of Immunology, Genetics and Pathology, Cancer Immunotherapy, Uppsala University, Uppsala, Sweden
| | - Ingrid Glimelius
- Department of Immunology, Genetics and Pathology, Cancer Precision Medicine, Uppsala University, Sweden
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8
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Marozoff S, Tan J, Lu N, Kirmani A, Loree JM, Xie H, Lacaille D, Kopec JA, Esdaile JM, Corradetti B, Malone P, Koehn CL, Mennell P, Hoens AM, Aviña-Zubieta JA. Effect of Immunosuppressive or Immunomodulatory Agents on Severe COVID-19 Outcomes: A Population-Based Cohort Study. ACR Open Rheumatol 2023. [PMID: 37818772 DOI: 10.1002/acr2.11620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVE We estimated the association between immunosuppressive and immunomodulatory agent (IIA) exposure and severe COVID-19 outcomes in a population-based cohort study. METHODS Participants were 18 years or older, tested positive for SARS-CoV-2 between February 6, 2020, and August 15, 2021, and were from administrative health data for the entire province of British Columbia, Canada. IIA use within 3 months prior to positive SARS-CoV-2 test included conventional disease-modifying antirheumatic drugs (antimalarials, methotrexate, leflunomide, sulfasalazine, individually), immunosuppressants (azathioprine, mycophenolate mofetil/mycophenolate sodium [MMF], cyclophosphamide, cyclosporine, individually and collectively), tumor necrosis factor inhibitor (TNFi) biologics (adalimumab, certolizumab, etanercept, golimumab, infliximab, collectively), non-TNFi biologics or targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) (rituximab separately from abatacept, anakinra, secukinumab, tocilizumab, tofacitinib and ustekinumab collectively), and glucocorticoids. Severe COVID-19 outcomes were hospitalizations for COVID-19, ICU admissions, and deaths within 60 days of a positive test. Exposure score-overlap weighting was used to balance baseline characteristics of participants with IIA use compared with nonuse of that IIA. Logistic regression measured the association between IIA use and severe COVID-19 outcomes. RESULTS From 147,301 participants, we identified 515 antimalarial, 573 methotrexate, 72 leflunomide, 180 sulfasalazine, 468 immunosuppressant, 378 TNFi biologic, 49 rituximab, 144 other non-TNFi biologic or tsDMARD, and 1348 glucocorticoid prescriptions. Risk of hospitalizations for COVID-19 was significantly greater for MMF (odds ratio [95% CI]): 2.82 [1.81-4.40], all immunosuppressants: 2.08 [1.51-2.87], and glucocorticoids: 1.63 [1.36-1.96], relative to nonuse. Similar outcomes were seen for ICU admission and MMF: 2.52 [1.34-4.74], immunosuppressants: 2.88 [1.73-4.78], and glucocorticoids: 1.86 [1.37-2.54]. Only glucocorticoids use was associated with a significant increase in 60-day mortality: 1.58 [1.21-2.06]. No other IIAs displayed statistically significant associations with severe COVID-19 outcomes. CONCLUSION Current use of MMF and glucocorticoids were associated with an increased risk of severe COVID-19 outcomes compared with nonuse. These results emphasize the variety of circumstances of patients taking IIAs.
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Affiliation(s)
- Shelby Marozoff
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Jeremiah Tan
- Arthritis Research Canada and University of British Columbia, Vancouver, Canada
| | - Na Lu
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Ayesha Kirmani
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | | | - Hui Xie
- Arthritis Research Canada, Vancouver, and Simon Fraser University, Burnaby, British Columbia, Canada
| | - Diane Lacaille
- Arthritis Research Canada and University of British Columbia, Vancouver, Canada
| | - Jacek A Kopec
- Arthritis Research Canada and University of British Columbia, Vancouver, Canada
| | - John M Esdaile
- Arthritis Research Canada and University of British Columbia, Vancouver, Canada
| | - Bonnie Corradetti
- Arthritis Research Canada, Vancouver, British Columbia, and Kidney Section of the Medicine Strategic Clinical Network, Alberta Health, Edmonton, Canada
| | - Peter Malone
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Cheryl L Koehn
- Arthritis Research Canada and Arthritis Consumer Experts, Vancouver, British Columbia, Canada
| | | | - Alison M Hoens
- Arthritis Research Canada and University of British Columbia, Vancouver, Canada
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9
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Bakirtzis C, Konstantinidou N, Stavropoulou De Lorenzo S, Moysiadis T, Boziki MK, Grigoriadou E, Kesidou E, Theotokis P, Thireos E, Mitrou P, Grigoriadis N. COVID-19 Vaccination and Disease Course in People with Multiple Sclerosis in Greece. J Clin Med 2023; 12:5460. [PMID: 37685528 PMCID: PMC10488265 DOI: 10.3390/jcm12175460] [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: 06/19/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Over the past three years, humanity faced the abrupt spread of COVID-19, responsible for a worldwide health crisis. Initially, it was believed that individuals with chronic disorders, including multiple sclerosis, were more likely to be infected and suffer a worse degree of COVID-19 disease. Therefore, data with regard to COVID-19 disease outcomes in these populations may provide additional insight with regard to the management of chronic diseases during viral pandemics. The objective of this study is to evaluate COVID-19 disease course in people with multiple sclerosis (PwMS) during the COVID-19 pandemic in Greece and explore the impact of vaccination in the outcome of SARS-CoV-2 infection in this population. Anonymized data, extracted from nationwide administrative records between February 2020 and December 2021, were retrospectively analyzed in order to identify PwMS with SARS-CoV-2 infection. Demographic data, as well as data regarding COVID-19 infection and vaccination, were additionally collected. The study sample included 2351 PwMS (65.1% females, 51.2% unvaccinated at the time of infection). A total of 260 PwMS were hospitalized, while 25 PwMS died from COVID-19 disease and its complications. Older age, male sex and the presence of comorbidities were independently associated with a higher probability of hospitalization. The risk of hospitalization was decreased in PwMS receiving some disease-modifying treatments. Anti-CD20s demonstrated high odds ratios without reaching statistical significance. Regarding fatal outcome, only age reached statistical significance. Vaccination provided a significant protective effect against hospitalization but did not exhibit a statistically significant effect on mortality.
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Affiliation(s)
- Christos Bakirtzis
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (N.K.); (S.S.D.L.); (M.-K.B.); (E.G.); (E.K.); (P.T.); (N.G.)
| | - Natalia Konstantinidou
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (N.K.); (S.S.D.L.); (M.-K.B.); (E.G.); (E.K.); (P.T.); (N.G.)
| | - Sotiria Stavropoulou De Lorenzo
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (N.K.); (S.S.D.L.); (M.-K.B.); (E.G.); (E.K.); (P.T.); (N.G.)
| | - Theodoros Moysiadis
- Department of Computer Science, School of Sciences and Engineering, University of Nicosia, 2417 Nicosia, Cyprus;
| | - Marina-Kleopatra Boziki
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (N.K.); (S.S.D.L.); (M.-K.B.); (E.G.); (E.K.); (P.T.); (N.G.)
| | - Eleni Grigoriadou
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (N.K.); (S.S.D.L.); (M.-K.B.); (E.G.); (E.K.); (P.T.); (N.G.)
| | - Evangelia Kesidou
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (N.K.); (S.S.D.L.); (M.-K.B.); (E.G.); (E.K.); (P.T.); (N.G.)
| | - Paschalis Theotokis
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (N.K.); (S.S.D.L.); (M.-K.B.); (E.G.); (E.K.); (P.T.); (N.G.)
| | - Eleftherios Thireos
- Primary Health Center of Vari, National Health System of Greece, 16672 Athens, Greece;
| | - Panagiota Mitrou
- Independent Department of Therapeutic Protocols and Patient Registers, Hellenic Ministry of Health, 10433 Athens, Greece;
| | - Nikolaos Grigoriadis
- Multiple Sclerosis Center, Second Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece; (N.K.); (S.S.D.L.); (M.-K.B.); (E.G.); (E.K.); (P.T.); (N.G.)
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10
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Jamali E, Shapoori S, Farrokhi MR, Vakili S, Rostamzadeh D, Iravanpour F, Tavakoli Oliaee R, Jafarinia M. Effect of Disease-Modifying Therapies on COVID-19 Vaccination Efficacy in Multiple Sclerosis Patients: A Comprehensive Review. Viral Immunol 2023; 36:368-377. [PMID: 37276047 DOI: 10.1089/vim.2023.0035] [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] [Indexed: 06/07/2023] Open
Abstract
According to current knowledge, the etiopathogenesis of multiple sclerosis (MS) is complex, involving genetic background as well as several environmental factors that result in dysimmunity in the central nervous system (CNS). MS is an immune-mediated, inflammatory neurological disease affecting the CNS. As part of its attack on the axons of the CNS, MS witnesses varying degrees of myelin and axonal loss. A total of about 20 disease-modifying therapies (DMTs) are available today that, both in clinical trials and in real-world studies, reduce disease activity, such as relapses, magnetic resonance imaging lesions, and disability accumulation. Currently, the world is facing an outbreak of the new coronavirus disease 2019 (COVID-19), which originated in Wuhan, Hubei Province, China, in December 2019 and spread rapidly around the globe. Viral infections play an important role in triggering and maintaining neuroinflammation through direct and indirect mechanisms. There is an old association between MS and viral infections. In the context of MS-related chronic inflammatory damage within the CNS, there has been concern regarding COVID-19 worsening neurological damage. A high rate of disability and increased susceptibility to infection have made MS patients particularly vulnerable. In addition, DMTs have been a concern during the pandemic since many DMTs have immunosuppressive properties. In this article, we discuss the impact of DMTs on COVID-19 risks and the effect of DMTs on COVID-19 vaccination efficacy and outcome in MS patients.
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Affiliation(s)
- Elham Jamali
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Peyvand Pathobiology and Genetic Laboratory, Shiraz, Iran
| | - Shima Shapoori
- Science Foundation Ireland (SFI), Center for Research in Medical Devices (CÚRAM), University of Galway, Galway, Ireland
| | - Majid Reza Farrokhi
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Neurosurgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sina Vakili
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Davoud Rostamzadeh
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
- Department of Immunology, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Farideh Iravanpour
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Razieh Tavakoli Oliaee
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Morteza Jafarinia
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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11
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Zaccardelli A, Wallace ZS, Sparks JA. Acute and postacute COVID-19 outcomes for patients with rheumatoid arthritis: lessons learned and emerging directions 3 years into the pandemic. Curr Opin Rheumatol 2023; 35:175-184. [PMID: 36752280 PMCID: PMC10065912 DOI: 10.1097/bor.0000000000000930] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
PURPOSE OF REVIEW To summarize the findings of studies investigating patients with rheumatoid arthritis (RA) and risk of acute and postacute COVID-19 outcomes 3 years into the pandemic. RECENT FINDINGS Most studies early in the pandemic included all patients with systemic autoimmune rheumatic diseases (SARDs), not only those with RA, due to limited sample size. Many of these studies found that patients with SARDs were at higher risk of COVID-19 infection and severe outcomes, including hospitalization, hyperinflammation, mechanical ventilation, and death. Studies performed later were able to focus on RA and found similar associations, while also identifying RA-specific factors such as immunosuppressive medications, disease activity/severity, and interstitial lung disease as risk factors for severe COVID-19. After COVID-19 vaccination, the risks for COVID-19 infection and severity were reduced for patients with RA, but a gap between the general population persisted, and some patients with RA are susceptible to breakthrough infection after vaccination. Preexposure prophylaxis, effective treatments, and changes in viral variants have also contributed to improved COVID-19 outcomes throughout the pandemic. Emerging data suggest that patients with RA may be at risk for postacute sequelae of COVID-19 (PASC). SUMMARY Although COVID-19 outcomes have improved over the pandemic for patients with RA, some experience poor acute and postacute outcomes after COVID-19. Clinicians and patients should remain vigilant about risk mitigation for infection and consider early treatment for RA patients with COVID-19. Future studies are needed to investigate clinical outcomes and mechanisms of PASC among patients with RA.
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Affiliation(s)
| | - Zachary S. Wallace
- Division of Rheumatology, Allergy, and Immunology
- Clinical Epidemiology Program, Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School
| | - Jeffrey A. Sparks
- Harvard Medical School
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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12
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Managing immunosuppression in vasculitis patients in times of COVID-19. Rheum Dis Clin North Am 2023. [PMCID: PMC10011035 DOI: 10.1016/j.rdc.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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13
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Qian G, Wang X, Patel NJ, Kawano Y, Fu X, Cook CE, Vanni KMM, Kowalski EN, Banasiak EP, Bade KJ, Srivatsan S, Williams ZK, Todd DJ, Weinblatt ME, Wallace ZS, Sparks JA. Outcomes with and without outpatient SARS-CoV-2 treatment for patients with COVID-19 and systemic autoimmune rheumatic diseases: a retrospective cohort study. THE LANCET. RHEUMATOLOGY 2023; 5:e139-e150. [PMID: 36844970 PMCID: PMC9940330 DOI: 10.1016/s2665-9913(23)00006-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background Some patients with systemic autoimmune rheumatic disease and immunosuppression might still be at risk of severe COVID-19. The effect of outpatient SARS-CoV-2 treatments on COVID-19 outcomes among patients with systemic autoimmune rheumatic disease is unclear. We aimed to evaluate temporal trends, severe outcomes, and COVID-19 rebound among patients with systemic autoimmune rheumatic disease and COVID-19 who received outpatient SARS-CoV-2 treatment compared with those who did not receive outpatient treatment. Methods We did a retrospective cohort study at Mass General Brigham Integrated Health Care System, Boston, MA, USA. We included patients aged 18 years or older with a pre-existing systemic autoimmune rheumatic disease, who had COVID-19 onset between Jan 23 and May 30, 2022. We identified COVID-19 by positive PCR or antigen test (index date defined as the date of first positive test) and systemic autoimmune rheumatic diseases using diagnosis codes and immunomodulator prescription. Outpatient SARS-CoV-2 treatments were confirmed by medical record review. The primary outcome was severe COVID-19, defined as hospitalisation or death within 30 days after the index date. COVID-19 rebound was defined as documentation of a negative SARS-CoV-2 test after treatment followed by a newly positive test. The association of outpatient SARS-CoV-2 treatment versus no outpatient treatment with severe COVID-19 outcomes was assessed using multivariable logistic regression. Findings Between Jan 23 and May 30, 2022, 704 patients were identified and included in our analysis (mean age 58·4 years [SD 15·9]; 536 [76%] were female and 168 [24%] were male, 590 [84%] were White and 39 [6%] were Black, and 347 [49%] had rheumatoid arthritis). Outpatient SARS-CoV-2 treatments increased in frequency over calendar time (p<0·0001). A total of 426 (61%) of 704 patients received outpatient treatment (307 [44%] with nirmatrelvir-ritonavir, 105 [15%] with monoclonal antibodies, five [1%] with molnupiravir, three [<1%] with remdesivir, and six [1%] with combination treatment). There were nine (2·1%) hospitalisations or deaths among 426 patients who received outpatient treatment compared with 49 (17·6%) among 278 who did not receive outpatient treatment (odds ratio [adjusted for age, sex, race, comorbidities, and kidney function] 0·12, 95% CI 0·05-0·25). 25 (7·9%) of 318 patients who received oral outpatient treatment had documented COVID-19 rebound. Interpretation Outpatient treatment was associated with lower odds of severe COVID-19 outcomes compared with no outpatient treatment. These findings highlight the importance of outpatient SARS-CoV-2 treatment for patients with systemic autoimmune rheumatic disease and COVID-19 and the need for further research on COVID-19 rebound. Funding None.
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Affiliation(s)
- Grace Qian
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Xiaosong Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Yumeko Kawano
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Claire E Cook
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Kathleen M M Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily N Kowalski
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily P Banasiak
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Katarina J Bade
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Shruthi Srivatsan
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Zachary K Williams
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Derrick J Todd
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Michael E Weinblatt
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Clinical Epidemiology Program, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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14
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Elahee M, Sattui SE. Navigating use of rituximab during the COVID-19 pandemic. THE LANCET. RHEUMATOLOGY 2023; 5:e63-e64. [PMID: 36644691 PMCID: PMC9831611 DOI: 10.1016/s2665-9913(23)00005-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Mehreen Elahee
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Sebastian E Sattui
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
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15
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Md Yusof MY, Arnold J, Saleem B, Vandevelde C, Dass S, Savic S, Vital EM, Emery P. Breakthrough SARS-CoV-2 infections and prediction of moderate-to-severe outcomes during rituximab therapy in patients with rheumatic and musculoskeletal diseases in the UK: a single-centre cohort study. THE LANCET. RHEUMATOLOGY 2023; 5:e88-e98. [PMID: 36712951 PMCID: PMC9873269 DOI: 10.1016/s2665-9913(23)00004-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Concerns have been raised regarding the reduced immunogenicity of vaccines against COVID-19 in patients with autoimmune diseases treated with rituximab. However, the incidence and severity of breakthrough infections in unbiased samples of patients with specific rheumatic and musculoskeletal diseases are largely unknown. We aimed to assess the incidence of breakthrough SARS-CoV-2 infection, compare rates of moderate-to-severe COVID-19 with any severe infection event, and evaluate predictors of moderate-to-severe COVID-19 outcomes in patients treated with rituximab. Methods We did a retrospective cohort study in all rituximab-treated patients with rheumatic and musculoskeletal diseases in a single centre in Leeds, UK between March 1, 2020 (the index date), and April 1, 2022. Adults aged 18 years and older, who fulfilled classification criteria for established rheumatic and musculoskeletal diseases, and received therapy with at least one rituximab infusion between Sept 1, 2019 (6 months before the pandemic in the UK), and April 1, 2022, were eligible for inclusion in the study. SARS-CoV-2 infection was defined by antigen test or PCR. COVID-19 outcomes were categorised as mild (from ambulatory to hospitalised but not requiring oxygen support) or moderate-to-severe (hospitalised and requiring oxygen support or death). The primary outcome was breakthrough COVID-19 infection, which was defined as an infection occurring 14 days or more after the second vaccine dose. Predictors of moderate-to-severe COVID-19 outcomes were analysed using Cox regression proportional hazards. Findings Of the 1280 patients who were treated with at least one cycle of rituximab since Jan 1, 2002, 485 (38%) remained on rituximab therapy on April 1, 2022. Of these patients, 400 fulfilled all inclusion criteria and were included in our final analysis. The mean age at the index date was 58·9 years (SD 14·6), 288 (72%) of 400 patients were female and 112 (28%) were male, 333 (83%) were White, and 110 (28%) had two or more comorbidities. 272 (68%) of 400 patients had rheumatoid arthritis, 48 (12%) had systemic lupus erythematosus, 48 (12%) had anti-neutrophil cytoplasmic antibody-associated vasculitis, and 46 (12%) had other rheumatic and musculoskeletal diseases. During the study, 798 rituximab cycles were administered. Of the 398 (>99%) of 400 patients with vaccine data, 372 (93%) were fully vaccinated. Over the 774·6 patient-years of follow-up, there was an incremental increase in all SARS-CoV-2 severity types over the three pandemic phases (wild-type or alpha, delta, and omicron), but most infections were mild. The rates of moderate-to-severe COVID-19 were broadly similar across these three variant phases. Of 370 patients who were fully vaccinated and with complete data, 110 (30%) had all severity type breakthrough COVID-19, 16 (4%) had moderate-to-severe breakthrough COVID-19, and one (<1%) died. In the post-vaccination phase (after Dec 18, 2020), the incidence rates of all severity type and moderate-to-severe COVID-19 were substantially lower in those who were fully vaccinated compared with unvaccinated or partially vaccinated individuals (22·83 per 100 person-years [95% CI 18·94-27·52] in those who were fully vaccinated vs 89·46 per 100 person-years [52·98-151·05] in those who were partially vaccinated or unvaccinated for infections of all severities, and 3·32 per 100 person-years [2·03-5·42] in those who were fully vaccinated vs 25·56 per 100 person-years [9·59-68·10] in those who were partially vaccinated or unvaccinated for moderate-to-severe infections). The rate of moderate-to-severe COVID-19 was broadly similar to other severe infection events in this cohort (5·68 per 100 person-years [95% CI 4·22-7·63]). In multivariable Cox regression analysis, factors associated with an increased risk of moderate-to-severe COVID-19 were the number of comorbidities (hazard ratio 1·46 [95% CI 1·13-1·89]; p=0·0037) and hypogammaglobulinaemia (defined by a pre-rituximab IgG concentration of <6 g/L; 3·22 [1·27-8·19]; p=0·014). This risk was reduced with each vaccine dose received (0·49 [0·37-0·65]; p<0·0001). Other factors, including concomitant prednisolone use, rituximab-associated factors (eg, rituximab dose and time to vaccination since last rituximab dose), and vaccine-associated factors (eg, vaccine type and peripheral B-cell depletion) were not predictive of moderate-to-severe COVID-19 outcomes. Interpretation This study presented detailed analyses of rituximab-treated patients during various phases of the COVID-19 pandemic. In later stages of the pandemic, the SARS-CoV-2 breakthrough infection rate was high but severe COVID-19 rates were similar to any severe infection event rate in patients who were vaccinated. The risk-benefit ratio might still favour rituximab in vaccinated patients with severe rheumatic and musculoskeletal diseases who have few other treatment options. Increased vigilance is needed in the presence of comorbidities and hypogammaglobulinaemia for all infection types. Funding Wellcome Trust and Eli Lilly.
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Affiliation(s)
- Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jack Arnold
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - Benazir Saleem
- Rheumatology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Claire Vandevelde
- Rheumatology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Shouvik Dass
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Rheumatology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sinisa Savic
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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16
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Lopedote P, Shadman M. Targeted Treatment of Relapsed or Refractory Follicular Lymphoma: Focus on the Therapeutic Potential of Mosunetuzumab. Cancer Manag Res 2023; 15:257-264. [PMID: 36941881 PMCID: PMC10024536 DOI: 10.2147/cmar.s381493] [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: 01/08/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
Follicular lymphoma is the most common indolent non-Hodgkin's lymphoma, and because of the incurable nature of this disorder, new therapies are constantly needed. The recently approved T-cell-dependent bispecific antibody mosunetuzumab showed promising results and manageable toxicities for patients with relapsed or refractory follicular lymphoma. Namely, as opposed to cellular immunotherapy options, this agent has the potential of being effective in patients with unfavorable features with a tolerable rate and severity of cytokine release syndrome, immune effector cell-associated neurotoxicity, and infectious complications. Given the recent withdrawal from the market of PI3K inhibitors and the practical challenges in utilizing with chimeric antigen receptor T-cells (CAR-T) for some patients, mosunetuzumab represents a "breath of fresh air" for both patients and hemato-oncologists. More data are required to better define the real potential of this molecule, either alone or in combination with other agents, including antibody drug conjugates, immunomodulators, and checkpoint inhibitors. Future studies will also shed light on the efficacy of mosunetuzumab compared with CAR-T, in well-designed registries or ideally in randomized controlled trials.
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Affiliation(s)
- Paolo Lopedote
- Department of Medicine, St Elizabeth’s Medical Center, Boston, MA, USA
| | - Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Correspondence: Mazyar Shadman, Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave, Seattle, WA, 98109, USA, Tel +1 206-667-5467, Email
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17
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Dimou A. Areas of Uncertainty in SARS-CoV-2 Vaccination for Cancer Patients. Vaccines (Basel) 2022; 10:vaccines10122117. [PMID: 36560527 PMCID: PMC9784623 DOI: 10.3390/vaccines10122117] [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: 08/30/2022] [Revised: 11/13/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
Early in the COVID-19 pandemic, it was recognized that infection with SARS-CoV-2 is associated with increased morbidity and mortality in patients with cancer; therefore, preventive vaccination in cancer survivors is expected to be particularly impactful. Heterogeneity in how a neoplastic disease diagnosis and treatment interferes with humoral and cellular immunity, however, poses a number of challenges in vaccination strategies. Herein, the available literature on the effectiveness of COVID-19 vaccines among patients with cancer is critically appraised under the lens of anti-neoplastic treatment optimization. The objective of this review is to highlight areas of uncertainty, where more research could inform future SARS-CoV-2 immunization programs and maximize benefits in the high-risk cancer survivor population, and also minimize cancer treatment deviations from standard practices.
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Affiliation(s)
- Anastasios Dimou
- Division of Medical Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
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18
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Figueroa-Parra G, Gilbert EL, Valenzuela-Almada MO, Vallejo S, Neville MR, Patel NJ, Cook C, Fu X, Hagi R, McDermott GC, Dilorio MA, Masto L, Vanni KMM, Kowalski E, Qian G, Zhang Y, Wallace ZS, Duarte-García A, Sparks JA. Risk of severe COVID-19 outcomes associated with rheumatoid arthritis and phenotypic subgroups: a retrospective, comparative, multicentre cohort study. THE LANCET. RHEUMATOLOGY 2022; 4:e765-e774. [PMID: 36118532 PMCID: PMC9472567 DOI: 10.1016/s2665-9913(22)00227-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Rheumatoid arthritis has been associated with severe COVID-19, but few studies have investigated how phenotypes of rheumatoid arthritis affect these associations. We aimed to investigate the associations between rheumatoid arthritis and phenotypes of interstitial lung disease, serostatus, and bone erosions with COVID-19 severity. Methods We did a retrospective, comparative, multicentre cohort study at two large health-care systems (Mayo Clinic [19 hospitals and affiliated outpatient centres] and Mass General Brigham [14 hospitals and affiliated outpatient centres]) in the USA. Consecutive patients with rheumatoid arthritis meeting the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria and who had COVID-19 between March 1, 2020, and June 6, 2021, were matched 1:5 on age, sex, and calendar date with patients without rheumatoid arthritis (comparators). Data were received from electronic health records from Mayo Clinic and Mass General Brigham. We examined subgroups of patients with rheumatoid arthritis by phenotypic features: rheumatoid arthritis-associated interstitial lung disease, seropositivity (for anti-cyclic citrullinated peptide, rheumatoid factor, or both), and bone erosions. Severe COVID-19 was a composite of hospitalisation or death. We used Cox regression to estimate hazard ratios (HR) for severe COVID-19, comparing rheumatoid arthritis and subgroups to the comparator group. Findings We identified 582 patients with rheumatoid arthritis and 2875 matched comparators, all of whom had COVID-19 within the study dates. The mean age of those with rheumatoid arthritis was 62 [SD 14] years, 421 (72%) of 582 were women and 161 (28%) were men, 457 (79%) were White, 65 (11%) were Hispanic or Latino, and 41 (7%) were Black. Among patients with rheumatoid arthritis, 50 (9%) of 582 had interstitial lung disease, 388 (68%) of 568 were seropositive, and 159 (27%) of 582 had bone erosions. Severe COVID-19 occurred in 126 (22%) of 582 patients with rheumatoid arthritis versus 363 (13%) 2875 in the comparator group. Patients with rheumatoid arthritis had an HR of 1·75 (95% CI 1·45-2·10) for severe COVID-19 versus the comparator group. Patients with rheumatoid arthritis-associated interstitial lung disease had an HR of 2·50 (1·66-3·77) versus the comparator group for severe COVID-19. The risk for severe COVID-19 was also higher in patients with rheumatoid arthritis who were seropositive (HR 1·97 [95% CI 1·58-2·46]) or had erosive disease (1·93 [1·41-2·63]) than for those in the comparator group. Interpretation Patients with rheumatoid arthritis have an increased risk of severe COVID-19 across phenotypic subgroups, especially among patients with interstitial lung disease. These findings suggest that rheumatoid arthritis with interstitial lung disease, or its treatment, might be a substantial contributor to severe COVID-19 outcomes for patients with rheumatoid arthritis. Funding None.
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Affiliation(s)
| | - Emily L Gilbert
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Matthew R Neville
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, AZ, USA
| | - Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Claire Cook
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Ramla Hagi
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory C McDermott
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael A Dilorio
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Lucy Masto
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Kathleen M M Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily Kowalski
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Grace Qian
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Alí Duarte-García
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
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19
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Qian G, Wang X, Patel NJ, Kawano Y, Fu X, Cook CE, Vanni KM, Kowalski EN, Banasiak EP, Bade KJ, Srivatsan S, Williams ZK, Todd DJ, Weinblatt ME, Wallace ZS, Sparks JA. Outcomes with and without outpatient SARS-CoV-2 treatment for patients with COVID-19 and systemic autoimmune rheumatic diseases: A retrospective cohort study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.10.27.22281629. [PMID: 36324801 PMCID: PMC9628202 DOI: 10.1101/2022.10.27.22281629] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective To investigate temporal trends, severe outcomes, and rebound among systemic autoimmune rheumatic disease (SARD) patients according to outpatient SARS-CoV-2 treatment. Methods We performed a retrospective cohort study investigating outpatient SARS-CoV-2 treatments among SARD patients at Mass General Brigham (23/Jan/2022-30/May/2022). We identified SARS-CoV-2 infection by positive PCR or antigen test (index date=first positive test) and SARDs using diagnosis codes and immunomodulator prescription. Outpatient treatments were confirmed by medical record review. The primary outcome was hospitalization or death within 30 days following the index date. COVID-19 rebound was defined as documentation of negative then newly-positive SARS-CoV-2 tests. The association of any vs. no outpatient treatment with hospitalization/death was assessed using multivariable logistic regression. Results We analyzed 704 SARD patients with COVID-19 (mean age 58.4 years, 76% female, 49% with rheumatoid arthritis). Treatment as outpatient increased over calendar time (p<0.001). A total of 426(61%) received outpatient treatment: 307(44%) with nirmatrelvir/ritonavir, 105(15%) with monoclonal antibodies, 5(0.7%) with molnupiravir, 3(0.4%) with outpatient remdesivir, and 6(0.9%) with combinations. There were 9/426 (2.1%) hospitalizations/deaths among those treated as outpatient compared to 49/278 (17.6%) among those with no outpatient treatment (adjusted odds ratio [aOR] 0.12, 0.05 to 0.25). 25/318 (8%) of patients who received oral outpatient treatment had documented COVID-19 rebound. Conclusion Outpatient treatment was strongly associated with lower odds of severe COVID-19 compared to no outpatient treatment. At least 8% of SARD patients experienced COVID-19 rebound. These findings highlight the importance of outpatient COVID-19 treatment for SARD patients and the need for further research on rebound. KEY MESSAGES What is already known on this topic? Previous studies suggest that monoclonal antibodies are an effective outpatient treatment option for patients at high-risk of severe COVID-19, including those with systemic autoimmune rheumatic diseases (SARDs).Nirmatrelvir/ritonavir and molnupiravir are recently-authorized effective oral outpatient SARS-CoV-2 treatment options, but clinical trials were performed among the general population, mostly among unvaccinated and prior to Omicron viral variants.Oral outpatient SARS-CoV-2 treatments may result in COVID-19 rebound, characterized by newly-positive COVID-19 testing and recurrent symptoms, but no studies have investigated rebound prevalence among SARD patients. What this study adds? This is one of the first studies investigating outpatient SARS-CoV-2 treatments among SARD patients that includes oral options and quantifies the prevalence of COVID-19 rebound.Outpatient treatment was associated with 88% reduced odds of severe COVID-19 compared to no treatment.At least 8% of SARDs receiving oral outpatient treatment experienced COVID-19 rebound. How this study might affect research practice or policy? These results should encourage clinicians to prescribe and SARD patients to seek prompt outpatient COVID-19 treatment.This research provides an early estimate of the prevalence of COVID-19 rebound after oral outpatient treatment to quantify this risk to clinicians and SARD patients and encourage future research.
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Affiliation(s)
- Grace Qian
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
| | - Xiaosong Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
| | - Naomi J. Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA (Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114)
- Harvard Medical School, Boston, MA
| | - Yumeko Kawano
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
- Harvard Medical School, Boston, MA
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA (Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114)
| | - Claire E. Cook
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA (Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114)
| | - Kathleen M.M. Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
| | - Emily N. Kowalski
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
| | - Emily P. Banasiak
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
| | - Katarina J. Bade
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
| | - Shruthi Srivatsan
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA (Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114)
| | - Zachary K. Williams
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA (Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114)
| | - Derrick J. Todd
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
- Harvard Medical School, Boston, MA
| | - Michael E. Weinblatt
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
- Harvard Medical School, Boston, MA
| | - Zachary S. Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA (Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114)
- Harvard Medical School, Boston, MA
- Clinical Epidemiology Program, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA (The Mongan Institute, 100 Cambridge Street, Suite 1600, Boston, MA, 02114)
| | - Jeffrey A. Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA (60 Fenwood Road, Boston, MA, 02115)
- Harvard Medical School, Boston, MA
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20
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Pugliatti M, Hartung HP, Oreja-Guevara C, Pozzilli C, Airas L, Alkhawajah M, Grigoriadis N, Magyari M, Van Wijmeersch B, Zakaria M, Linker R, Chan A, Vermersch P, Berger T. Anti-SARS-CoV-2 vaccination in people with multiple sclerosis: Lessons learnt a year in. Front Immunol 2022; 13:1045101. [PMID: 36325318 PMCID: PMC9620960 DOI: 10.3389/fimmu.2022.1045101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/26/2022] [Indexed: 11/22/2022] Open
Abstract
It has been over a year since people with multiple sclerosis (pwMS) have been receiving vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). With a negligible number of cases in which vaccination led to a relapse or new onset MS, experts around the world agree that the potential consequences of COVID-19 in pwMS by far outweigh the risks of vaccination. This article reviews the currently available types of anti-SARS-CoV-2 vaccines and the immune responses they elicit in pwMS treated with different DMTs. Findings to date highlight the importance of vaccine timing in relation to DMT dosing to maximize protection, and of encouraging pwMS to get booster doses when offered.
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Affiliation(s)
- Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
- Interdepartmental Center of Research for Multiple Sclerosis and Neuro-inflammatory and Degenerative Diseases, University of Ferrara, Ferrara, Italy
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Palacky University Olomouc, Olomouc, Czechia
- *Correspondence: Hans-Peter Hartung,
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
- Faculty of Medicine, Complutense University of Madrid (UCM), Madrid, Spain
| | - Carlo Pozzilli
- Multiple Sclerosis Center, S. Andrea Hospital, Department of Human Neuroscience, University Sapienza, Rome, Italy
| | - Laura Airas
- Division of Clinical Neurosciences, University of Turku, Turku, Finland
- Neurocenter of Turku University Hospital, Turku, Finland
| | - Mona Alkhawajah
- Section of Neurology, Neurosciences Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine, Al Faisal University, Riyadh, Saudi Arabia
| | - Nikolaos Grigoriadis
- Laboratory of Experimental Neurology and Neuroimmunology, Second Department of Neurology, American Hellenic Educational Progressive Association (AHEPA) University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Bart Van Wijmeersch
- Universitair Multiple Sclerosis (MS) Centrum, Hasselt-Pelt, Belgium
- Revalidatie & Multiple Sclerosis (MS), Noorderhart, Pelt, Belgium
- Rehabilitation Research Center (REVAL) & Biomedical Research Institute (BIOMED), Hasselt University, Hasselt, Belgium
| | - Magd Zakaria
- Department of Neurology, Ain Shams University, Cairo, Egypt
| | - Ralf Linker
- Clinic and Polyclinic for Neurology, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Andrew Chan
- Department of Neurology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Vermersch
- University of Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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21
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Calabrese C, Kirchner E, Villa-Forte A, Hajj-Ali RA, Moss BP, Fernandez JP, Calabrese L. Early experience with tixagevimab/cilgavimab pre-exposure prophylaxis in patients with immune-mediated inflammatory disease undergoing B cell depleting therapy and those with inborn errors of humoral immunity. RMD Open 2022; 8:rmdopen-2022-002557. [PMID: 36123015 PMCID: PMC9485640 DOI: 10.1136/rmdopen-2022-002557] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/03/2022] Open
Affiliation(s)
- Cassandra Calabrese
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Elizabeth Kirchner
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alexandra Villa-Forte
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rula A Hajj-Ali
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brandon P Moss
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - James P Fernandez
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Leonard Calabrese
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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22
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Sparks JA, Singh N, Wallace ZS. Effectiveness of COVID-19 vaccination in immune-mediated inflammatory diseases. THE LANCET. RHEUMATOLOGY 2022; 4:e380-e382. [PMID: 35441152 PMCID: PMC9009834 DOI: 10.1016/s2665-9913(22)00109-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Namrata Singh
- Division of Rheumatology, University of Washington, Seattle, WA, USA
| | - Zachary S Wallace
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Epidemiology Program, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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23
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Patel NJ, Stone JH. Expert Perspective: Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Rheumatol 2022; 74:1305-1317. [PMID: 35289109 DOI: 10.1002/art.42114] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/11/2022] [Accepted: 03/09/2022] [Indexed: 12/30/2022]
Abstract
The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) comprise a major subset of diseases that cause destructive inflammation of small and medium-sized blood vessels. Although these conditions have a predilection for pulmonary and renal involvement, they are in fact protean diseases that can involve essentially any organ system. AAV is among the most difficult rheumatic diseases to diagnose and treat. Therapy for AAV has evolved over the past two decades. Rituximab, an anti-CD20 monoclonal antibody, is now the preferred agent for remission induction in conjunction with a reduced-dose glucocorticoid taper. Rituximab is also often a key therapy for remission maintenance. Glucocorticoid toxicity reduction has become a major priority for treatment regimens. Avacopan, an important new adjunct to remission induction therapy, may reduce glucocorticoid use and its resulting toxicity. The role of avacopan as a remission maintenance agent requires further study. The duration of immunosuppression following remission is guided by a number of factors, including the patient's overall clinical state, the degree of damage from previous disease activity, the tolerability of remission maintenance medications, and SARS-CoV-2 vaccination and immunity status. Certain features, including history of previous relapse, the presence of ANCA directed against proteinase 3, and a diagnosis of granulomatosis with polyangiitis, favor prolonged remission maintenance therapy. The interval between rituximab doses can usually be lengthened over time during the maintenance phase.
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