[Updated recommendations of the German Society for Rheumatology for the care of patients with inflammatory rheumatic diseases in the context of the SARS-CoV‑2/COVID‑19 pandemic, including recommendations for COVID‑19 vaccination]

[The German Society for Rheumatology and Clinical Immunology (DGRh) and the COVID-19 pandemic]

The pandemic led to a global disruption of public life unprecedented in modern times due to an infectious disease, which certainly caused additional special burdens for patients with chronic diseases as well as for personnel in the healthcare system. The German Society of Rheumatology and Clinical Immunology (DGRh), with its Executive Board and two ad hoc commissions, responded promptly to the complex challenges posed by the pandemic for rheumatological care in Germany with provision of a comprehensive and professionally sound range of information and provided concrete assistance in many situations. The diverse activities of the DGRh in the context of the pandemic led to national and international attention and consideration of its committees and recommendations in national committees and guidelines.

Type of vaccine and immunosuppressive therapy but not diagnosis critically influence antibody response after COVID-19 vaccination in patients with rheumatic disease

OBJECTIVE

The development of sufficient COVID-19 vaccines has been a big breakthrough in fighting the global SARS-CoV-2 pandemic. However, vaccination effectiveness can be reduced in patients with autoimmune rheumatic diseases (AIRD). The aim of this study was to identify factors that lead to a diminished humoral vaccination response in patients with AIRD.

METHODS

Vaccination response was measured with a surrogate virus neutralisation test and by testing for antibodies directed against the receptor-binding-domain (RBD) of SARS-CoV-2 in 308 fully vaccinated patients with AIRD. In addition, 296 immunocompetent participants were investigated as a control group. Statistical adjusted analysis included covariates with a possible influence on antibody response.

RESULTS

Patients with AIRD showed lower antibody responses compared with immunocompetent individuals (median neutralising capacity 90.8% vs 96.5%, p<0.001; median anti-RBD-IgG 5.6 S/CO vs 6.7 S/CO, p<0.001). Lower antibody response was significantly influenced by type of immunosuppressive therapy, but not by rheumatic diagnosis, with patients under rituximab therapy developing the lowest antibody levels. Patients receiving mycophenolate, methotrexate or janus kinase inhibitors also showed reduced vaccination responses. Additional negative influencing factors were vaccination with AZD1222, old age and shorter intervals between the first two vaccinations.

CONCLUSION

Certain immunosuppressive therapies are associated with lower antibody responses after vaccination. Additional factors such as vaccine type, age and vaccination interval should be taken into account. We recommend antibody testing in at-risk patients with AIRD and emphasise the importance of booster vaccinations in these patients.

Pausing methotrexate improves immunogenicity of COVID-19 vaccination in elderly patients with rheumatic diseases

OBJECTIVE

To study the effect of methotrexate (MTX) and its discontinuation on the humoral immune response after COVID-19 vaccination in patients with autoimmune rheumatic diseases (AIRD).

METHODS

In this retrospective study, neutralising SARS-CoV-2 antibodies were measured after second vaccination in 64 patients with AIRD on MTX therapy, 31 of whom temporarily paused medication without a fixed regimen. The control group consisted of 21 patients with AIRD without immunosuppressive medication.

RESULTS

Patients on MTX showed a significantly lower mean antibody response compared with patients with AIRD without immunosuppressive therapy (71.8% vs 92.4%, p<0.001). For patients taking MTX, age correlated negatively with immune response (r=-0.49; p<0.001). All nine patients with antibody levels below the cut-off were older than 60 years. Patients who held MTX during at least one vaccination showed significantly higher mean neutralising antibody levels after second vaccination, compared with patients who continued MTX therapy during both vaccinations (83.1% vs 61.2%, p=0.001). This effect was particularly pronounced in patients older than 60 years (80.8% vs 51.9%, p=0.001). The impact of the time period after vaccination was greater than of the time before vaccination with the critical cut-off being 10 days.

CONCLUSION

MTX reduces the immunogenicity of SARS-CoV-2 vaccination in an age-dependent manner. Our data further suggest that holding MTX for at least 10 days after vaccination significantly improves the antibody response in patients over 60 years of age.

[COVID-19 and inflammatory rheumatic diseases]

Older age, cardiovascular comorbidities, chronic lung diseases, and GC use were identified as independent risk factors for severe courses of COVID-19 resulting in the need of hospitalization. Glucocorticoid dosis of > 10 mg over a longer period of time should be very carefully used as there are various immunomodulatory alternatives. Of particular note, disease activity of inflammatory rheumatic diseases (IRD) was also identified as an independent predictor of COVID-19 related hospitalization.Already in the early phase of the pandemic case reports of fatal courses of IRD patients under treatment with rituximab were reported. Meanwhile, several data could demonstrate higher rates of hospitalization and COVID-19-related deaths. Whether a similar effect is detectable regarding Janus kinase inhibitors in patients with rheumatoid arthritis is currently under investigation.Preliminary data indicate that all available COVID-19 vaccines in Europe are not associated with higher rates of disease flares or differences of side effect profiles compared to the general population. There is no recommendation to discontinue or reduce immunomodulatory treatment in general to achieve better immune response. In the case of Rituximab, consideration should be given to postponing or switching to alternative therapies, taking into account the risk of reactivation of the underlying disease on the one hand and the improvement of a potential vaccine response on the other.

[Are SARS-CoV-2 reactive T cells detectable and potentially protective in patients under anti-CD20 treatment with an impaired humoral response?]

The pandemic attributable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has greatly changed life in most countries of the world for more than 1.5 years now. The spread could be more or less well-controlled and fatalities could partly be avoided by obligatory wearing of masks, contact restrictions and since the beginning of the year by vaccinations. Patients with chronic inflammatory diseases and organ transplant patients under immunosuppression, are somewhat more at risk to become ill with coronavirus disease 2019 (COVID-19). The probability and severity of an infection depends on the ability of the humoral and cellular immune systems to effectively combat the virus. This can be substantially improved by vaccination. The B cell depleting monoclonal antibody rituximab (RTX) is frequently employed in rheumatic diseases, whereby antibody formation against the new pathogen within the framework of vaccination is restricted. Recent study results in patients treated with RTX indicate that an effective cellular immune response can be developed despite the impaired humoral response.

[COVID-19 in Routine Rheumatologic Care]

Seit dem ersten Fall einer Infektion mit SARS‐CoV‐2 („severe acute respiratory syndrome coronavirus 2“) und der damit assoziierten COVID-19-Erkrankung („corona virus disease 19“) existiert eine weltweite Pandemie. Diese führt zu anhaltenden, weitreichenden Folgen für das Gesundheitssystem und die Gesellschaft insgesamt. Unsere Patienten mit entzündlich-rheumatischen Erkrankungen galten initial, insbesondere bei bestehender immunsuppressiver und/oder immunmodulatorischer Therapie (DMARD), als hochgefährdet, sich mit SARS‐CoV‐2 zu infizieren. Man nahm an, dass es im Fall einer Infektion zu einem schweren COVID‐19-Verlauf kommen könnte. Die PCR-Diagnostik gilt zwar gemeinhin als Goldstandard zur Frühdiagnose einer aktiven Infektion mit SARS-CoV‑2, es zeigt sich jedoch, dass sie nicht immer zur Diagnosesicherung von COVID-19 als solches gewertet werden sollte. Eine ergänzende Antikörpertestung scheint empfehlenswert und kann bei typischer Symptomatologie auch noch rückwirkend zur Diagnosesicherung Abhilfe schaffen. Dem Anschein nach sind Patienten mit einer entzündlich-rheumatischen Erkrankung und unter einer DMARD-Therapie im Fall einer SARS-CoV-2-Infektion nicht grundsätzlich besonders gefährdet. Ob dies an besseren Hygienemaßnahmen oder verstärkten Kontaktbeschränkungen der Patienten mit entzündlich-rheumatischer Grunderkrankung liegt oder ob die laufende DMARD-Therapie einen gewissen Schutz vor einem schweren Verlauf von COVID-19 bietet, lässt sich aus den vorliegenden Daten nicht sagen. Die wichtigen Fragen zur Verträglichkeit und Wirksamkeit der COVID-19-Impfung sind noch nicht zu beantworten. Zusammenfassend besteht weiterhin ein deutlicher Forschungsbedarf, um unsere Patienten besser beraten zu können.