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Athni TS, Barmettler S. Hypogammaglobulinemia, late-onset neutropenia, and infections following rituximab. Ann Allergy Asthma Immunol 2023; 130:699-712. [PMID: 36706910 PMCID: PMC10247428 DOI: 10.1016/j.anai.2023.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that targets CD20-expressing B lymphocytes, has a well-defined efficacy and safety profile, and is broadly used to treat a wide array of diseases. In this review, we cover the mechanism of action of rituximab and focus on hypogammaglobulinemia and late-onset neutropenia-2 immune effects secondary to rituximab-and subsequent infection. We review risk factors and highlight key considerations for immunologic monitoring and clinical management of rituximab-induced secondary immune deficiencies. In patients treated with rituximab, monitoring for hypogammaglobulinemia and infections may help to identify the subset of patients at high risk for developing poor B cell reconstitution, subsequent infections, and adverse complications. These patients may benefit from early interventions such as vaccination, antibacterial prophylaxis, and immunoglobulin replacement therapy. Systematic evaluation of immunoglobulin levels and peripheral B cell counts by flow cytometry, both at baseline and periodically after therapy, is recommended for monitoring. In addition, in those patients with prolonged hypogammaglobulinemia and increased infections after rituximab use, immunologic evaluation for inborn errors of immunity may be warranted to further risk stratification, increase monitoring, and assist in therapeutic decision-making. As the immunologic effects of rituximab are further elucidated, personalized approaches to minimize the risk of adverse reactions while maximizing benefit will allow for improved care of patients with decreased morbidity and mortality.
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Affiliation(s)
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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2
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Blincoe A, Labrosse R, Abraham RS. Acquired B-cell deficiency secondary to B-cell-depleting therapies. J Immunol Methods 2022; 511:113385. [PMID: 36372267 DOI: 10.1016/j.jim.2022.113385] [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: 06/19/2022] [Revised: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022]
Abstract
The advantage of the newer biological therapies is that the immunosuppressive effect is targeted, in contrast, to the standard, traditional immunomodulatory agents, which have a more global effect. However, there are unintended targets and consequences, even to these "precise" therapeutics, leading to acquired or secondary immunodeficiencies. Besides depleting specific cellular immune subsets, these biological agents, which include monoclonal antibodies against biologically relevant molecules, often have broader functional immune consequences, which become apparent over time. This review focuses on acquired B-cell immunodeficiency, secondary to the use of B-cell depleting therapeutic agents. Among the many adverse consequences of B-cell depletion is the risk of hypogammaglobulinemia, failure of B-cell recovery, impaired B-cell differentiation, and risk of infections. Factors, which modulate the outcomes of B-cell depleting therapies, include the intrinsic nature of the underlying disease, the concomitant use of other immunomodulatory agents, and the clinical status of the patient and other co-existing morbidities. This article seeks to explore the mechanism of action of B-cell depleting agents, the clinical utility and adverse effects of these therapies, and the relevance of systematic and serial laboratory immune monitoring in identifying patients at risk for developing immunological complications, and who may benefit from early intervention to mitigate the secondary consequences. Though these biological drugs are gaining widespread use, a harmonized approach to immune evaluation pre-and post-treatment has not yet gained traction across multiple clinical specialties, because of which, the true prevalence of these adverse events cannot be determined in the treated population, and a systematic and evidence-based dosing schedule cannot be developed. The aim of this review is to bring these issues into focus, and initiate a multi-specialty, data-driven approach to immune monitoring.
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Affiliation(s)
- Annaliesse Blincoe
- Department of Paediatric Immunology and Allergy, Starship Child Health, Auckland, NZ, New Zealand
| | - Roxane Labrosse
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Canada
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
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3
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Guaracha-Basañez GA, Contreras-Yáñez I, Álvarez-Hernández E, Reyes-Cordero G, Flores-Alvarado DE, González-Chávez SA, Galarza-Delgado DÁ, Martínez-Leyva PR, Moctezuma-Ríos JF, García-García C, Medrano-Ramírez G, Gastelum-Strozzi A, Pacheco-Tena C, Peláez-Ballestas I, Pascual-Ramos V. Factors associated to COVID-19 vaccine acceptance in Mexican patients with rheumatic diseases: A cross-sectional and multicenter study. Hum Vaccin Immunother 2022; 18:2049131. [PMID: 35389817 PMCID: PMC9196644 DOI: 10.1080/21645515.2022.2049131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
COVID-19 vaccination is recommended in patients with rheumatic diseases (RDs) to prevent hospitalized COVID-19 and worse outcomes. However, patients’ willingness to receive a SARS-CoV-2 vaccine and the associated factors vary across populations, vaccines, and time. The objective was to identify factors associated with COVID-19 vaccine acceptance (VA) in Mexican outpatients with RDs. This multicenter study was performed between March 1 and September 30, 2021, and four national centers contributed with patients. Participants filled out a questionnaire, which included 32 items related to patients’ perception of the patient-doctor relationship, the COVID-19 vaccine component, the pandemic severity, the RD-related disability, comorbid conditions control, immunosuppressive treatment impact on the immune system, and moral/civil position of COVID-19 vaccine. Sociodemographic, disease-related, and treatment-related variables and previous influenza record vaccination were also obtained. Multiple logistic regression analyses identified factors associated with VA, which was defined based on a questionnaire validated in our population. There were 1439 patients whose data were analyzed, and the most frequent diagnoses were Rheumatoid Arthritis in 577 patients (40.1%) and Systemic Lupus Erythematosus in 427 (29.7%). Patients were primarily middle-aged women (1235 [85.8%]), with (mean±SD) 12.1 (±4.4) years of formal education. Years of education, corticosteroid use, patient perceptions about the vaccine and the pandemic severity, patient civil/moral position regarding COVID-19 vaccine, and previous influenza vaccination were associated with VA. In Mexican patients with RDs, COVID-19 VA is associated with individual social-demographic and disease-related factors, patient´s perceptions, and previous record vaccination. This information is crucial for tailoring effective vaccine messaging in Mexican patients with RDs.
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Affiliation(s)
- Guillermo Arturo Guaracha-Basañez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Irazú Contreras-Yáñez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | | | | | - Diana Elsa Flores-Alvarado
- Rheumatology Department, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - Dionicio Ángel Galarza-Delgado
- Rheumatology Department, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Perla Rocío Martínez-Leyva
- Rheumatology Department, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - Conrado García-García
- Department of Rheumatology, Hospital General de México "Dr. Eduardo Liceaga", México City, México
| | - Gabriel Medrano-Ramírez
- Department of Rheumatology, Hospital General de México "Dr. Eduardo Liceaga", México City, México
| | | | - César Pacheco-Tena
- Facultad de Medicina y Universidad Autónoma de Chihuahua, Chihuahua, Mexico
| | - Ingris Peláez-Ballestas
- Department of Rheumatology, Hospital General de México "Dr. Eduardo Liceaga", México City, México
| | - Virginia Pascual-Ramos
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
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4
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Di Iorio M, Cook CE, Vanni KM, Patel NJ, D'Silva KM, Fu X, Wang J, Prisco LC, Kowalski E, Zaccardelli A, Martin LW, Qian G, Hsu TYT, Wallace ZS, Sparks JA. DMARD disruption, rheumatic disease flare, and prolonged COVID-19 symptom duration after acute COVID-19 among patients with rheumatic disease: A prospective study. Semin Arthritis Rheum 2022; 55:152025. [PMID: 35617780 PMCID: PMC9116968 DOI: 10.1016/j.semarthrit.2022.152025] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/22/2022] [Accepted: 05/10/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To describe disease-modifying antirheumatic drug (DMARD) disruption, rheumatic disease flare/activity, and prolonged COVID-19 symptom duration among COVID-19 survivors with systemic autoimmune rheumatic diseases (SARDs). METHODS We surveyed people with pre-existing SARDs who had confirmed COVID-19 at Mass General Brigham to investigate post-acute sequelae of COVID-19. We obtained data on demographics, clinical characteristics, COVID-19 symptoms/course, and patient-reported measures. We examined baseline predictors of prolonged COVID-19 symptom duration (defined as lasting ≥28 days) using logistic regression. RESULTS We analyzed surveys from 174 COVID-19 survivors (mean age 52 years, 81% female, 80% White, 50% rheumatoid arthritis) between March 2021 and January 2022. Fifty-one percent of 127 respondents on any DMARD reported a disruption to their regimen after COVID-19 onset. For individual DMARDs, 56-77% had any change, except for hydroxychloroquine (23%) and rituximab (46%). SARD flare after COVID-19 was reported by 41%. Global patient-reported disease activity was worse at the time of survey than before COVID-19 (mean 6.6±2.9 vs. 7.6±2.3, p<0.001). Median time to COVID-19 symptom resolution was 25 days (IQR 11, 160). Prolonged symptom duration of ≥28 days occurred in 45%. Hospitalization for COVID-19 (OR 3.54, 95%CI 1.27-9.87) and initial COVID-19 symptom count (OR 1.38 per symptom, 95%CI 1.17-1.63) were associated with prolonged symptom duration. Respondents experiencing prolonged symptom duration had higher RAPID3 scores (p=0.007) and more pain (p<0.001) and fatigue (p=0.03) compared to those without prolonged symptoms. CONCLUSION DMARD disruption, SARD flare, and prolonged COVID-19 symptom duration were common in this prospective study of COVID-19 survivors, suggesting substantial impact on SARDs after acute COVID-19.
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Affiliation(s)
- Michael Di Iorio
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | - Claire E. Cook
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Kathleen M.M. Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States
| | - Naomi J. Patel
- Harvard Medical School, Boston, MA, United States,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Kristin M. D'Silva
- Harvard Medical School, Boston, MA, United States,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Jiaqi Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States
| | - Lauren C. Prisco
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States
| | - Emily Kowalski
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States
| | - Alessandra Zaccardelli
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States
| | - Lily W. Martin
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States
| | - Grace Qian
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States
| | - Tiffany Y-T. Hsu
- Harvard Medical School, Boston, MA, United States,Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States
| | - Zachary S. Wallace
- Harvard Medical School, Boston, MA, United States,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, United States,Clinical Epidemiology Program, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Jeffrey A. Sparks
- Harvard Medical School, Boston, MA, United States,Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA 02115, United States,Corresponding author
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5
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Di Iorio M, Cook CE, Vanni KM, Patel NJ, D’Silva KM, Fu X, Wang J, Prisco LC, Kowalski E, Zaccardelli A, Martin LW, Qian G, Hsu TYT, Wallace ZS, Sparks JA. DMARD disruption, disease flare, and prolonged symptom duration after acute COVID-19 among participants with rheumatic disease: A prospective study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.02.08.22270696. [PMID: 35169813 PMCID: PMC8845434 DOI: 10.1101/2022.02.08.22270696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To describe disease-modifying antirheumatic drug (DMARD) disruption, rheumatic disease flare/activity, and prolonged COVID-19 symptom duration among COVID-19 survivors with systemic autoimmune rheumatic diseases (SARDs). METHODS We surveyed patients with SARDs after confirmed COVID-19 at Mass General Brigham to investigate post-acute sequelae of COVID-19. We obtained data on demographics, clinical characteristics, COVID-19 symptoms/course, and patient-reported measures. We examined baseline predictors of prolonged COVID-19 symptom duration (defined as lasting ≥28 days) using logistic regression. RESULTS We analyzed surveys from 174 COVID-19 survivors (mean age 52 years, 81% female, 80% White, 50% rheumatoid arthritis) between March 2021 and January 2022. Fifty-one percent of 127 respondents on any DMARD reported a disruption to their regimen after COVID-19 onset. For individual DMARDs, 56-77% had any change, except for hydroxychloroquine (23%) and rituximab (46%). SARD flare after COVID-19 was reported by 41%. Global patient-reported disease activity was worse at the time of survey than before COVID-19 (mean 6.6±2.9 vs. 7.6±2.3, p<0.001). Median time to COVID-19 symptom resolution was 14 days (IQR 9,29). Prolonged symptom duration of ≥28 days occurred in 45%. Hospitalization for COVID-19 (OR 3.54, 95%CI 1.27-9.87) and initial COVID-19 symptom count (OR 1.38 per symptom, 95%CI 1.17-1.63) were associated with prolonged symptom duration. Respondents experiencing prolonged symptom duration had higher RAPID3 scores (p=0.007) and more pain (p<0.001) and fatigue (p=0.03) compared to those without prolonged symptoms. CONCLUSION DMARD disruption, SARD flare, and prolonged symptom duration were common in this prospective study of COVID-19 survivors, suggesting substantial impact on SARDs after acute COVID-19.
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Affiliation(s)
- Michael Di Iorio
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA,Harvard Medical School, 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
| | - Naomi J. Patel
- Harvard Medical School, Boston, MA, USA,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Kristin M. D’Silva
- Harvard Medical School, Boston, MA, USA,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
| | - Jiaqi Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lauren C. Prisco
- 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
| | - Alessandra Zaccardelli
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lily W. Martin
- 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
| | - Tiffany Y-T. Hsu
- Harvard Medical School, Boston, MA, USA,Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Zachary S. Wallace
- 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
| | - Jeffrey A. Sparks
- Harvard Medical School, Boston, MA, USA,Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
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Sattui SE, Robinson PC. The COVID-19 Pandemic and Rheumatology: Impact on Providing Care in Latin America and Around the World. J Rheumatol 2021; 48:1501-1503. [PMID: 34334356 DOI: 10.3899/jrheum.210774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The novel coronavirus pandemic has affected the world, importantly, from a health perspective. Initial concern about all rheumatology patients being at risk has given way to a more nuanced view of the risks.1.
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Affiliation(s)
- Sebastian E Sattui
- S.E. Sattui, MD, MS, Assistant Professor of Medicine, Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; P.C. Robinson, MB ChB, PhD, Associate Professor, University of Queensland School of Clinical Medicine, Faculty of Medicine, and Royal Brisbane & Women's Hospital, Metro North Hospital & Health Service, Herston, Queensland, Australia. PCR reports personal fees from AbbVie, Atom Biosciences, Eli Lilly, Gilead, Janssen, Novartis, UCB, Roche, and Pfizer; meeting attendance support from BMS, Eli Lilly, Pfizer, and UCB; and grant funding from Janssen, Novartis, Pfizer, and UCB Pharma. SES declares no conflicts of interest relevant to this article. Address correspondence to Assoc. Prof. P.C. Robinson, University of Queensland School of Clinical Medicine, Royal Brisbane & Women's Hospital, Herston, Queensland 4006, Australia.
| | - Philip C Robinson
- S.E. Sattui, MD, MS, Assistant Professor of Medicine, Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; P.C. Robinson, MB ChB, PhD, Associate Professor, University of Queensland School of Clinical Medicine, Faculty of Medicine, and Royal Brisbane & Women's Hospital, Metro North Hospital & Health Service, Herston, Queensland, Australia. PCR reports personal fees from AbbVie, Atom Biosciences, Eli Lilly, Gilead, Janssen, Novartis, UCB, Roche, and Pfizer; meeting attendance support from BMS, Eli Lilly, Pfizer, and UCB; and grant funding from Janssen, Novartis, Pfizer, and UCB Pharma. SES declares no conflicts of interest relevant to this article. Address correspondence to Assoc. Prof. P.C. Robinson, University of Queensland School of Clinical Medicine, Royal Brisbane & Women's Hospital, Herston, Queensland 4006, Australia.
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