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Omelchenko VO, Kurochkina YD, Fedorova AV, Ovchinnikov VS, Koval VV, Bratko IV, Letyagina EA, Korolev MA. Analysis of T-cell and Humoral Immune Response to SARS-CoV-2 Antigens in Rituximab-Treated Patients with Rheumatoid Arthritis Vaccinated with Combined Vector Vaccine Gam-COVID-Vac. Bull Exp Biol Med 2024; 176:786-790. [PMID: 38896315 DOI: 10.1007/s10517-024-06109-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Indexed: 06/21/2024]
Abstract
The COVID-19 pandemic has brought significant changes in managing of patients with rheumatoid arthritis. Rituximab-treated patients were more susceptible to severe infection. This required a "switch" to another genetically engineered drug in the patients with high risk of adverse COVID-19. In this study, we assessed the severity of immune response to SARS-CoV-2 antigens in rituximab-treated patients with rheumatoid arthritis vaccinated with the combined vector vaccine Gam-COVID-Vac. Insufficient formation of the humoral response and a high level of T-cell response to SARS-CoV-2 antigens in this group of patients were revealed. An imbalance of cellular and humoral response may play a role in more severe COVID-19 in rituximab-treated patients with rheumatoid arthritis.
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Affiliation(s)
- V O Omelchenko
- Laboratory of Connective Tissue Pathology, Research Institute of Clinical and Experimental Lymphology - Branch of the Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia.
| | - Yu D Kurochkina
- Laboratory of Connective Tissue Pathology, Research Institute of Clinical and Experimental Lymphology - Branch of the Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - A V Fedorova
- Laboratory of Connective Tissue Pathology, Research Institute of Clinical and Experimental Lymphology - Branch of the Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - V S Ovchinnikov
- Laboratory of Connective Tissue Pathology, Research Institute of Clinical and Experimental Lymphology - Branch of the Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - V V Koval
- Laboratory of Connective Tissue Pathology, Research Institute of Clinical and Experimental Lymphology - Branch of the Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - I V Bratko
- Laboratory of Connective Tissue Pathology, Research Institute of Clinical and Experimental Lymphology - Branch of the Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - E A Letyagina
- Laboratory of Connective Tissue Pathology, Research Institute of Clinical and Experimental Lymphology - Branch of the Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - M A Korolev
- Laboratory of Connective Tissue Pathology, Research Institute of Clinical and Experimental Lymphology - Branch of the Federal Research Center Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
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2
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Mv P, Auanassova A, Yessirkepov M, Zimba O, Gasparyan AY, Kitas GD, Ahmed S. New-onset systemic vasculitis following SARS-CoV-2 infection and vaccination: the trigger, phenotype, and outcome. Clin Rheumatol 2023; 42:2761-2775. [PMID: 37422611 DOI: 10.1007/s10067-023-06694-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/13/2023] [Accepted: 07/02/2023] [Indexed: 07/10/2023]
Abstract
The global health crisis caused by the COVID-19 pandemic overwhelmed the capacity of healthcare systems to cope with the rapidly spreading infection and its associated complications. Among these complications, autoimmune phenomena such as systemic vasculitis emerged as a significant challenge. Both the SARS-CoV-2 virus and the vaccines developed to combat it appeared to induce clinical manifestations resembling various types of systemic vasculitis, affecting large, medium, and small vessels. These virus- or vaccine-induced vasculitides exhibited a distinct natural history and course from de novo vasculitis, as they were more responsive to steroid therapy and some mild cases even resolved spontaneously. Notably, there have been no confirmed cases of SARS-CoV-2 infection or vaccination triggering variable vessel vasculitis like Behcet's disease or Kawasaki disease. IgA vasculitis, which is predominantly a pediatric condition, was more prevalent in adults after COVID-19 infection and they had a favorable outcome with glucocorticoid treatment. The impact of immunosuppression, especially B-cell-depleting agents, on the immunogenicity of the vaccine was evident, but there was no significant increase in the incidence of SARS-CoV-2 infection in these patients compared to the general population. Considering their relatively benign course, these post-COVID or post-vaccine vasculitides seem to be amenable to 0.8 to 1 mg/kg prednisolone or equivalent, which could be gradually tapered. The need for immunosuppression and the duration of steroid therapy should be determined on an individual basis. While the world still reels from the perils of a deadly pandemic, the aftermath continues to haunt. Our narrative review aims to explore the effects of COVID and the vaccine on systemic vasculitis, as well as the effect of disease and immunosuppression on the immunogenicity of the COVID vaccine.
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Affiliation(s)
- Prakashini Mv
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, India, 751024
| | - Akerke Auanassova
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Olena Zimba
- Department of Clinical Rheumatology and Immunology, University Hospital in Krakow, Krakow, Poland
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Department of Internal Medicine N2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Armen Yuri Gasparyan
- Departments of Rheumatology and Research and Development, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Russells Hall Hospital, Dudley, West Midlands, UK
| | - George D Kitas
- Departments of Rheumatology and Research and Development, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Russells Hall Hospital, Dudley, West Midlands, UK
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, India, 751024.
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Antovic A, Bruchfeld A, Ekland J, Lövström B, Hugelius A, Börjesson O, Knight A, Gunnarsson I. Risks and treatment related aspects of COVID-19 infection in patients with ANCA-associated vasculitis. Scand J Rheumatol 2022:1-6. [PMID: 36124819 DOI: 10.1080/03009742.2022.2109337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) require immunosuppressive therapy for disease control and relapse prevention and may be at risk for severe coronavirus disease 2019 (COVID-19). The study objective was to analyse risk factors and outcomes of COVID-19 in well-characterized AAV patients. METHOD Data were retrieved from March 2020 to May 2021 from medical records of AAV cohorts in Stockholm and Uppsala, Sweden. COVID-19 was confirmed by positive PCR test or by ELISA. Severe COVID-19 was defined as need for non-invasive ventilation, intensive care unit care, and/or death. Age, gender, ANCA antibody type, ongoing immunosuppressive medication, and estimated glomerular filtration rate were recorded. RESULTS The cohort comprised 310 AAV patients, of whom 29 (9%) were diagnosed with COVID-19. Four deaths were attributed to COVID-19. Fifteen patients (52%) were on prednisolone in the COVID-19 group and 130 (46%) in the non-COVID group, with significantly higher doses in COVID-19 patients (p < 0.01). Ongoing induction therapy was more prevalent in the COVID-19 group (p < 0.01). Severe COVID-19 was diagnosed in 9/29 (31%). Significant risk factors for severe COVID-19 were impaired kidney function (p = 0.01) and more intense immunosuppressive therapy (p = 0.02), with a trend for age (p = 0.07). Maintenance therapy with rituximab was not associated with severe COVID-19. CONCLUSIONS Our findings highlight risks and suggest that more attention should be given to optimal AAV treatment in a pandemic situation. They also emphasize the need for continued shielding, mitigation strategies, and effective vaccination of AAV patients.
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Affiliation(s)
- A Antovic
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Solna, Sweden.,Unit of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - A Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Renal Medicine, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - J Ekland
- Rheumatology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - B Lövström
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Solna, Sweden.,Unit of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - A Hugelius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Solna, Sweden.,Unit of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - O Börjesson
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Solna, Sweden.,Unit of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - A Knight
- Rheumatology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - I Gunnarsson
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Solna, Sweden.,Unit of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
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4
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Immunosuppression and SARS-CoV-2 Infection in Kidney Transplant Recipients. Transplant Direct 2022; 8:e1292. [PMID: 35187216 PMCID: PMC8843373 DOI: 10.1097/txd.0000000000001292] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/15/2021] [Accepted: 12/27/2021] [Indexed: 12/15/2022] Open
Abstract
Kidney transplant recipients (KTRs) infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may have an increased risk of mortality compared with the general population and hemodialysis patients. As these patients are immunosuppressed, it might seem obvious to attribute this excess mortality to the impaired immunity induced by immunosuppression. In line with this reasoning is the low immune response, both cellular and humoral, that KTRs mount in response to the anti–SARS-CoV-2 vaccine; however, acute respiratory distress syndrome associated with coronavirus disease 2019 is triggered by a state of inflammation and cytokine release syndrome that lead to pulmonary damage and increased mortality. In that context, immunosuppressive treatment dampening the immune response could, in theory, be potentially beneficial. This review aims at analyzing the current knowledge on the impact of immunosuppressive treatment on mortality in SARS-CoV-2–infected KTRs, the optimal management of immunosuppression in the coronavirus disease 2019 era, and the vaccine response and management in immunosuppressed KTRs.
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Sakano T, Bittner EA, Chang MG. Severe COVID pneumonia and undetectable B cells after vaccination in patients previously treated with rituximab: a case series. Postgrad Med 2022; 134:239-243. [PMID: 35129061 DOI: 10.1080/00325481.2022.2037359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The risk of developing severe COVID-19 illness despite completing vaccination for patients who have previously received immunosuppressive therapy is unclear. CASE PRESENTATION We present three patients who received rituximab for treatment of autoimmune disorders who subsequently developed severe COVID-19 pneumonia post-vaccination requiring intensive care unit admission and found to have undetectable B cells. DISCUSSION While there have been concerns about the effectiveness of COVID-19 vaccines in this patient cohort, this is the first case series to report development of severe COVID-19 illness after completing vaccination in those who previously received rituximab. Guidelines for the optimal timing of COVID-19 vaccination in relation to immunosuppressive therapy have been recently published, albeit after many patients in this subpopulation have already been vaccinated. CONCLUSION This case series brings attention to the limited humoral response to vaccines in patients treated with rituximab, highlights existing guidelines and their limitations, and raises future considerations about the potential benefits to testing vaccine responsiveness.
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Affiliation(s)
- Takashi Sakano
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Edward A Bittner
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marvin G Chang
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
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Floyd L, Elsayed ME, Seibt T, von Bergwelt-Baildon A, Seo P, Antiochos B, Kant S, Morris A, Dhaygude A, Schönermarck U, Geetha D. SARS-CoV-2 vaccine response in ANCA associated vasculitis patients. Kidney Int Rep 2021; 7:629-632. [PMID: 34926870 PMCID: PMC8664608 DOI: 10.1016/j.ekir.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- Lauren Floyd
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Mohamed E Elsayed
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Tobias Seibt
- Nephrology Division, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | | | - Philip Seo
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Brendan Antiochos
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sam Kant
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adam Morris
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ajay Dhaygude
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ulf Schönermarck
- Nephrology Division, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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7
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The COVID-19 pandemic and ANCA-associated vasculitis - reports from the EUVAS meeting and EUVAS education forum. Autoimmun Rev 2021; 20:102986. [PMID: 34718165 PMCID: PMC8552556 DOI: 10.1016/j.autrev.2021.102986] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/24/2021] [Indexed: 01/17/2023]
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic influenced the management of patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. A paucity of data exists on outcome of patients with vasculitis following COVID-19, but mortality is higher than in the general population and comparable to patients undergoing haemodialysis or kidney transplant recipients (reported mortality rates of 20-25%). Delays in diagnosis have been reported, which are associated with sequelae such as dialysis-dependency. Management of ANCA-associated vasculitis has not changed with the aim to suppress disease activity and reduce burden of disease. The use of rituximab, an important and widely used agent, is associated with a more severe hospital course of COVID-19 and absence of antibodies following severe acute respiratory syndrome (SARS)-CoV-2 infections, which prone patients to re-infection. Reports on vaccine antibody response are scarce at the moment, but preliminary findings point towards an impaired immune response, especially when patients receive rituximab as part of their treatment. Seropositivity was reported in less than 20% of patients when rituximab was administered within the prior six months, and the antibody response correlated with CD19+ B-cell repopulation. A delay in maintenance doses, if disease activity allows, has been suggested using a CD19+ B-cell guided strategy. Other immunosuppressive measures, which are used in ANCA-associated vasculitis, also impair humoral and cellular vaccine responses. Regular measurements of vaccine response or a healthcare-policy time-based strategy are indicated to provide additional doses ("booster") of COVID-19 vaccines. This review summarizes a recent educational forum and a recent virtual meeting of the European Vasculitis Society (EUVAS) focusing on COVID-19.
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8
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Hatami P, Balighi K, Nicknam Asl H, Aryanian Z. COVID vaccination in patients under treatment with rituximab: A presentation of two cases from Iran and a review of the current knowledge with a specific focus on pemphigus. Dermatol Ther 2021; 35:e15216. [PMID: 34811862 PMCID: PMC9011959 DOI: 10.1111/dth.15216] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/19/2021] [Accepted: 11/16/2021] [Indexed: 12/19/2022]
Abstract
SARS‐COV2 vaccines were approved without long‐term monitoring due to emergent situations. This has raised some issues about the timing and protocol of receiving vaccines in specific situations such as patients receiving immunomodulatory agents including rituximab, which is widely used for various disorders such as multiple sclerosis, pemphigus, and many rheumatologic disorders. We described two cases of pemphigus vulgaris (a new case and one with flare‐up) following vaccination with Astrazeneca in Iran and reviewed the existing data in this regard through searching on PubMed, Google Scholar, and Scopus. All of the relevant papers published until June 28, 2021, which we could access their full‐texts were included. We found some recommendations made by rheumatologists, neurologists, and dermatologists in regard to vaccination timing in this group of patients and tried to summarize them to provide a practical guide for clinicians. Clinicians should perform a careful, individualized risk–benefit assessment for their patients and consider a delay in rituximab administration after completion of COVID vaccination if there is not any considerable risk of disease relapse or organ failure. Moreover, choosing vaccines with potential of providing protection after single dose, especially in countries with limited access to vaccines may be a reasonable approach.
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Affiliation(s)
- Parvaneh Hatami
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Balighi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Nicknam Asl
- Department of Dentistry, Rafsanjan University of Medical Sciences (RUMS), Rafsanjan, Iran
| | - Zeinab Aryanian
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Dermatology, Babol University of Medical Sciences, Babol, Iran
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De Novo and Relapsing Glomerulonephritis following SARS-CoV-2 mRNA Vaccination in Microscopic Polyangiitis. Case Rep Nephrol 2021. [PMID: 34254648 PMCID: PMC8556126 DOI: 10.1155/2021/8400842] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Vaccination against SARS-CoV-2 is the most important advance in the fight against the ongoing coronavirus pandemic. Recent case reports show that the SARS-CoV-2 vaccines can very rarely cause de novo or relapsing glomerular disease. Here, we report two female patients with microscopic polyangiitis, who developed severe glomerulonephritis after immunisation with the BNT162b2 mRNA vaccine. One patient with a possible ongoing but undiagnosed disease developed severe necrotising glomerulonephritis after the second vaccination. In the other patient with a long-lasting disease, rituximab maintenance therapy had been postponed because of the coronavirus pandemic. She noted macrohematuria immediately after the second vaccine dose and developed a severe renal relapse leading to end-stage kidney disease. We suggest that patients with ANCA-associated vasculitis be carefully monitored for disease activity immediately before and after receiving the SARS-CoV-2 vaccination, especially if maintenance therapy has been interrupted. Ultimately, mRNA vaccines should probably be avoided in these patients.
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10
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Managing ANCA-associated vasculitis during the COVID-19 pandemic: results from an online survey. Rheumatol Int 2021; 41:1941-1947. [PMID: 34427760 PMCID: PMC8382578 DOI: 10.1007/s00296-021-04975-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/14/2021] [Indexed: 11/17/2022]
Abstract
Management of ANCA-associated vasculitis (AAV) during the COVID-19 pandemic poses unique therapeutic challenges. An online survey was conducted to understand physician’s choices for treating AAV during the COVID-19 pandemic. Web-based survey featuring nineteen questions was circulated amongst physicians across various specialties. The responses regarding immunosuppressive therapy for remission induction and maintenance, COVID-19 testing, and preventive measures were recorded. A total of 304 responses were recorded. Most of the respondents were from India (83.9%) and comprised rheumatologists (66%) in practice for ≥ 5 years (71%). Though a majority preferred Rituximab or intravenous cyclophosphamide (CYC) as a remission induction agent, a significant proportion opted for oral CYC and mycophenolate mofetil (MMF) also. Only one-third wanted to test for COVID-19 before initiating immunosuppressive therapy in patients with organ/life-threatening manifestations. Rituximab was the most favored maintenance therapy (47%), followed by azathioprine, MMF, and methotrexate. The results of this focused survey of managing AAV patients depict the real-world dilemmas and physicians’ choices in this setting.
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