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Park JK, Kim M, Jung JI, Kim JY, Jeong H, Park JW, Winthrop KL, Lee EB. Immunogenicity, reactogenicity, and safety of two-dose adjuvanted herpes zoster subunit vaccine in patients with systemic lupus erythematosus in South Korea: a single-centre, randomised, double-blind, placebo-controlled trial. THE LANCET. RHEUMATOLOGY 2024; 6:e352-e360. [PMID: 38710192 DOI: 10.1016/s2665-9913(24)00084-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/14/2024] [Accepted: 03/19/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND The adjuvanted herpes zoster subunit vaccine has shown good efficacy and safety in the general population. However, its effectiveness has not been comprehensively assessed in patients with systemic lupus erythematosus (SLE). This study aimed to evaluate the immunogenicity and safety of the adjuvanted herpes zoster subunit vaccine in patients with SLE. METHODS This single-centre, randomised, double-blind, placebo-controlled, trial was done at the rheumatology outpatient clinic at Seoul National University Hospital, South Korea. Patients (aged ≥19 years) with clinically stable SLE and previous exposure (≥4 weeks) to immunosuppressive drugs were randomly assigned (4:1) via a central interactive web response system to receive herpes zoster subunit vaccine or placebo (0·5 mL intramuscular injection) at weeks 0 and 8. Investigators and participants were masked to intervention and group assignment. Anti-glycoprotein E antibody titres and glycoprotein E-specific cell-mediated vaccine responses were evaluated at baseline and at week 8 after the first dose, and at week 4, week 26, and week 52 after the second dose using enzyme-linked immunosorbent assay and flow cytometry, respectively. Reactogenicity, SLE disease activity, including Systemic Lupus Erythematosus Disease Activity Index 2000 and British Isles Lupus Assessment Group-flare rate, were examined. The primary outcome was the proportion of patients with a positive humoral vaccine response 4 weeks after the second dose. The primary and safety analyses were done in a modified intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT06001606. FINDINGS Between June 14, and July 19, 2023, 65 patients with SLE were enrolled, of whom 52 were randomly assigned to the herpes zoster subunit vaccine and 13 to placebo. 49 patients in the vaccine group and 11 patients in the placebo group were included in the modified intention-to-treat population. 56 (93%) of 60 patients were women and four (7%) were men. Mean age was 48·7 years (SD 11·4). The proportion of participants with a humoral vaccine response at 4 weeks after the second dose was significantly higher in the vaccine group (48 [98%] of 49 participants) than the placebo group (none [0%] of 11 patients; p<0·0001). More patients in the vaccine group than placebo group reported injection site reactions (42 patients vs two patients), fever (ten vs none), and fatigue (26 vs two). There were no differences in Systemic Lupus Erythematosus Disease Activity Index 2000 and British Isles Lupus Assessment Group-flare rates between the groups. There were no treatment-related deaths. INTERPRETATION The herpes zoster subunit vaccine induces humoral and cellular immunity against herpes zoster with a good safety profile in patients with SLE. A larger study is warranted to assess the efficacy of vaccines to prevent herpes zoster in patients with SLE. FUNDING Ministry of Science and ICT, The Government of the Republic of Korea.
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Affiliation(s)
- Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Miriam Kim
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea
| | - Ji In Jung
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ju Yeon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea
| | - Heejin Jeong
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kevin L Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea.
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Jiang Y, Sadun RE. What the SARS-CoV-2 Pandemic Has Taught Us About Immunosuppression, Vaccinations, and Immune Dysregulation: The Rheumatology Experience. Curr Allergy Asthma Rep 2024; 24:221-232. [PMID: 38568321 DOI: 10.1007/s11882-024-01139-9] [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: 02/26/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE OF REVIEW This review reflects on the impact of the COVID-19 pandemic on the field of rheumatology, emphasizing resulting insights related to the risks of viral infections in immunosuppressed patients, vaccine immunogenicity in immunocompromised patients, and immune dysregulation in the setting of viral infection. RECENT FINDINGS During the pandemic, global patient registries provided real-time insights into the risk factors associated with severe COVID-19 outcomes in rheumatology patients. Updated evidence-based recommendations from the American College of Rheumatology (ACR) guided rheumatology practice during a time of considerable uncertainty. Studies on COVID-19 vaccines in immunocompromised populations enhanced our understanding of specific immunosuppressive therapies on vaccine efficacy. The immune dysregulation seen in severe COVID-19 underscored a role for immunomodulation in this and other severe infections. Furthermore, novel post-infectious conditions, namely multisystem inflammatory syndrome in children (MIS-C) and Long COVID, reshaped our understanding of post-viral syndromes and revealed novel pathological mechanisms. Lessons from the COVID-19 pandemic demonstrate the power of collaborative research. The scientific revelations from this dreadful time will, nonetheless, benefit the practice of rheumatology for years to come.
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Affiliation(s)
- Yike Jiang
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca E Sadun
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
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Sarin KY, Zheng H, Chaichian Y, Arunachalam PS, Swaminathan G, Eschholz A, Gao F, Wirz OF, Lam B, Yang E, Lee LW, Feng A, Lewis MA, Lin J, Maecker HT, Boyd SD, Davis MM, Nadeau KC, Pulendran B, Khatri P, Utz PJ, Zaba LC. Impaired innate and adaptive immune responses to BNT162b2 SARS-CoV-2 vaccination in systemic lupus erythematosus. JCI Insight 2024; 9:e176556. [PMID: 38456511 PMCID: PMC10972586 DOI: 10.1172/jci.insight.176556] [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: 10/10/2023] [Accepted: 01/30/2024] [Indexed: 03/09/2024] Open
Abstract
Understanding the immune responses to SARS-CoV-2 vaccination is critical to optimizing vaccination strategies for individuals with autoimmune diseases, such as systemic lupus erythematosus (SLE). Here, we comprehensively analyzed innate and adaptive immune responses in 19 patients with SLE receiving a complete 2-dose Pfizer-BioNTech mRNA vaccine (BNT162b2) regimen compared with a control cohort of 56 healthy control (HC) volunteers. Patients with SLE exhibited impaired neutralizing antibody production and antigen-specific CD4+ and CD8+ T cell responses relative to HC. Interestingly, antibody responses were only altered in patients with SLE treated with immunosuppressive therapies, whereas impairment of antigen-specific CD4+ and CD8+ T cell numbers was independent of medication. Patients with SLE also displayed reduced levels of circulating CXC motif chemokine ligands, CXCL9, CXCL10, CXCL11, and IFN-γ after secondary vaccination as well as downregulation of gene expression pathways indicative of compromised innate immune responses. Single-cell RNA-Seq analysis reveals that patients with SLE showed reduced levels of a vaccine-inducible monocyte population characterized by overexpression of IFN-response transcription factors. Thus, although 2 doses of BNT162b2 induced relatively robust immune responses in patients with SLE, our data demonstrate impairment of both innate and adaptive immune responses relative to HC, highlighting a need for population-specific vaccination studies.
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Affiliation(s)
| | - Hong Zheng
- Institute for Immunity, Transplantation and Infection
- Center for Biomedical Informatics Research, Department of Medicine, School of Medicine, and
| | - Yashaar Chaichian
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, California, USA
| | - Prabhu S. Arunachalam
- Institute for Immunity, Transplantation and Infection
- Department of Immunobiology, University of Arizona, Tucson, Arizona, USA
| | | | | | - Fei Gao
- Institute for Immunity, Transplantation and Infection
| | | | | | - Emily Yang
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, California, USA
| | - Lori W. Lee
- Department of Pediatrics, Division of Pediatric Pulmonary Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Allan Feng
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, California, USA
| | | | - Janice Lin
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, California, USA
| | | | | | - Mark M. Davis
- Institute for Immunity, Transplantation and Infection
- Department of Microbiology and Immunology, Howard Hughes Medical Institute, Stanford University, Stanford, California, USA
| | - Kari C. Nadeau
- Institute for Immunity, Transplantation and Infection
- Department of Environmental Gealth, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Bali Pulendran
- Department of Pathology and
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford University, Stanford, California, USA
| | - Purvesh Khatri
- Institute for Immunity, Transplantation and Infection
- Center for Biomedical Informatics Research, Department of Medicine, School of Medicine, and
| | - Paul J. Utz
- Institute for Immunity, Transplantation and Infection
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, California, USA
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4
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Abhishek A, Peckham N, Pade C, Gibbons JM, Cureton L, Francis A, Barber V, Williams JAE, Appelbe D, Eldridge L, Julier P, Altmann DM, Bluett J, Brooks T, Coates LC, Rombach I, Semper A, Otter A, Valdes AM, Nguyen-Van-Tam JS, Williams HC, Boyton RJ, McKnight Á, Cook JA. Effect of a 2-week interruption in methotrexate treatment on COVID-19 vaccine response in people with immune-mediated inflammatory diseases (VROOM study): a randomised, open label, superiority trial. THE LANCET. RHEUMATOLOGY 2024; 6:e92-e104. [PMID: 38267107 DOI: 10.1016/s2665-9913(23)00298-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Methotrexate is the first-line treatment for immune-mediated inflammatory diseases and reduces vaccine-induced immunity. We evaluated if a 2-week interruption of methotrexate treatment immediately after COVID-19 booster vaccination improved antibody response against the S1 receptor binding domain (S1-RBD) of the SARS-CoV-2 spike protein and live SARS-CoV-2 neutralisation compared with uninterrupted treatment in patients with immune-mediated inflammatory diseases. METHOD We did a multicentre, open-label, parallel-group, randomised, superiority trial in secondary-care rheumatology and dermatology clinics in 26 hospitals in the UK. Adults (aged ≥18 years) with immune-mediated inflammatory diseases taking methotrexate (≤25 mg per week) for at least 3 months, who had received two primary vaccine doses from the UK COVID-19 vaccination programme were eligible. Participants were randomly assigned (1:1) using a centralised validated computer program, to temporarily suspend methotrexate treatment for 2 weeks immediately after COVID-19 booster vaccination or continue treatment as usual. The primary outcome was S1-RBD antibody titres 4 weeks after COVID-19 booster vaccination and was assessed masked to group assignment. All randomly assigned patients were included in primary and safety analyses. This trial is registered with ISRCTN, ISRCTN11442263; following a pre-planned interim analysis, recruitment was stopped early. FINDING Between Sept 30, 2021, and March 7, 2022, we screened 685 individuals, of whom 383 were randomly assigned: to either suspend methotrexate (n=191; mean age 58·8 years [SD 12·5], 118 [62%] women and 73 [38%] men) or to continue methotrexate (n=192; mean age 59·3 years [11·9], 117 [61%] women and 75 [39%] men). At 4 weeks, the geometric mean S1-RBD antibody titre was 25 413 U/mL (95% CI 22 227-29 056) in the suspend methotrexate group and 12 326 U/mL (10 538-14 418) in the continue methotrexate group with a geometric mean ratio (GMR) of 2·08 (95% CI 1·59-2·70; p<0·0001). No intervention-related serious adverse events occurred. INTERPRETATION 2-week interruption of methotrexate treatment in people with immune-mediated inflammatory diseases enhanced antibody responses after COVID-19 booster vaccination that were sustained at 12 weeks and 26 weeks. There was a temporary increase in inflammatory disease flares, mostly self-managed. The choice to suspend methotrexate should be individualised based on disease status and vulnerability to severe outcomes from COVID-19. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
| | - Nicholas Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Corinna Pade
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joseph M Gibbons
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Vicki Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Jennifer A E Williams
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Patrick Julier
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Daniel M Altmann
- Department of Inflammation and Immunology, Imperial College London, London, UK
| | - James Bluett
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester UK; Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | | | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Biomedical Research Centre, Oxford, UK
| | - Ines Rombach
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, UK
| | | | | | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, London, UK; Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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5
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Bechman K, Galloway J. Improving COVID-19 vaccine response in individuals receiving methotrexate. THE LANCET. RHEUMATOLOGY 2024; 6:e67-e68. [PMID: 38267103 DOI: 10.1016/s2665-9913(23)00306-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 11/12/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Katie Bechman
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London WC2R 2LS, UK.
| | - James Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London WC2R 2LS, UK
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6
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Martínez-Fleta P, Vicente-Rabaneda EF, Triguero-Martínez A, Roy-Vallejo E, Uriarte-Ecenarro M, Gutiérrez-Rodríguez F, Quiroga-Colina P, Romero-Robles A, Montes N, García-Castañeda N, Mejía-Abril GP, García-Vadillo JA, Llorente-Cubas I, Villagrasa JR, Serra López-Matencio JM, Ancochea J, Urzainqui A, Esparcia-Pinedo L, Alfranca A, de la Fuente H, García-Vicuña R, Sánchez-Madrid F, González-Álvaro I, Castañeda S. Beneficial effect of temporary methotrexate interruption on B and T cell responses upon SARS-CoV-2 vaccination in patients with rheumatoid arthritis or psoriatic arthritis. NPJ Vaccines 2024; 9:21. [PMID: 38291047 PMCID: PMC10827732 DOI: 10.1038/s41541-024-00805-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/02/2024] [Indexed: 02/01/2024] Open
Abstract
B and T cell responses were evaluated in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) after 1 or 2 weeks of methotrexate (MTX) withdrawal following each COVID-19 vaccine dose and compared with those who maintained MTX. Adult RA and PsA patients treated with MTX were recruited and randomly assigned to 3 groups: MTX-maintenance (n = 72), MTX-withdrawal for 1 week (n = 71) or MTX-withdrawal for 2 weeks (n = 73). Specific antibodies to several SARS-CoV-2 antigens and interferon (IFN)-γ and interleukin (IL)-21 responses were assessed. MTX withdrawal in patients without previous COVID-19 was associated with higher levels of anti-RBD IgG and neutralising antibodies, especially in the 2-week withdrawal group and with higher IFN-γ secretion upon stimulation with pools of SARS-CoV-2 S peptides. No increment of RA/PsA relapses was detected across groups. Our data indicate that two-week MTX interruption following COVID-19 vaccination in patients with RA or PsA improves humoral and cellular immune responses.
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Affiliation(s)
- Pedro Martínez-Fleta
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Esther F Vicente-Rabaneda
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Ana Triguero-Martínez
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Emilia Roy-Vallejo
- Department of Internal Medicine, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Miren Uriarte-Ecenarro
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Francisco Gutiérrez-Rodríguez
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Patricia Quiroga-Colina
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Ana Romero-Robles
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Nuria Montes
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Noelia García-Castañeda
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Gina P Mejía-Abril
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Jesús A García-Vadillo
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Irene Llorente-Cubas
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - José R Villagrasa
- Department of Preventive Medicine, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - José M Serra López-Matencio
- Department of Hospital Pharmacy, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Julio Ancochea
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Department of Pneumology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Cátedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Ana Urzainqui
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Laura Esparcia-Pinedo
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
| | - Arantzazu Alfranca
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- CIBER Cardiovascular CIBERCV, Madrid, Spain
| | - Hortensia de la Fuente
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- CIBER Cardiovascular CIBERCV, Madrid, Spain
| | - Rosario García-Vicuña
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Francisco Sánchez-Madrid
- Department of Immunology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- CIBER Cardiovascular CIBERCV, Madrid, Spain
| | - Isidoro González-Álvaro
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain.
| | - Santos Castañeda
- Department of Rheumatology, Hospital Universitario de La Princesa IIS-Princesa (Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa), Madrid, Spain.
- Cátedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain.
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7
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Picchianti-Diamanti A, Navarra A, Aiello A, Laganà B, Cuzzi G, Salmi A, Vanini V, Maggi F, Meschi S, Matusali G, Notari S, Agrati C, Salemi S, Di Rosa R, Passarini D, Di Gioia V, Sesti G, Conti F, Spinelli FR, Corpolongo A, Chimenti MS, Ferraioli M, Sebastiani GD, Benucci M, Li Gobbi F, Santoro AP, Capri A, Puro V, Nicastri E, Goletti D. Older Age, a High Titre of Neutralising Antibodies and Therapy with Conventional DMARDs Are Associated with Protection from Breakthrough Infection in Rheumatoid Arthritis Patients after the Booster Dose of Anti-SARS-CoV-2 Vaccine. Vaccines (Basel) 2023; 11:1684. [PMID: 38006015 PMCID: PMC10675674 DOI: 10.3390/vaccines11111684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
Objectives: We aimed to analyse the incidence and severity of breakthrough infections (BIs) in rheumatoid arthritis (RA) patients after a COronaVIrus Disease 2019 (COVID-19) vaccination booster dose. Methods: We enrolled 194 RA patients and 1002 healthcare workers (HCWs) as controls. Clinical, lifestyle and demographic factors were collected at the time of the third dose, and immunogenicity analyses were carried out in a subgroup of patients at 4-6 weeks after the third dose. Results: BIs were experienced by 42% patients (82/194) with a median time since the last vaccination of 176 days. Older age (>50 years; aHR 0.38, 95% CI: 0.20-0.74), receiving conventional synthetic disease modifying antirheumatic drugs (csDMARDs) (aHR 0.52, 95%CI: 0.30-0.90) and having a titre of neutralising antibodies >20 (aHR 0.36, 95% CI: 0.12-1.07) were identified as protective factors. Conversely, anti-IL6R treatment and anti-CD20 therapy increased BI probability. BIs were mostly pauci-symptomatic, but the hospitalisation incidence was significantly higher than in HCWs (8.5% vs. 0.19%); the main risk factor was anti-CD20 therapy. Conclusions: Being older than 50 years and receiving csDMARDs were shown to be protective factors for BI, whereas anti-IL6R or anti-CD20 therapy increased the risk. Higher neutralising antibody titres were associated with a lower probability of BI. If confirmed in a larger population, the identification of a protective cut-off would allow a personalised risk-benefit therapeutic management of RA patients.
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Affiliation(s)
- Andrea Picchianti-Diamanti
- Department of Clinical and Molecular Medicine, “Sapienza” University, S. Andrea University Hospital, 00189 Rome, Italy; (A.P.-D.); (B.L.); (S.S.); (R.D.R.); (D.P.); (V.D.G.); (G.S.)
| | - Assunta Navarra
- Epidemiology Department, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy;
| | - Alessandra Aiello
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.A.); (G.C.); (A.S.); (V.V.)
| | - Bruno Laganà
- Department of Clinical and Molecular Medicine, “Sapienza” University, S. Andrea University Hospital, 00189 Rome, Italy; (A.P.-D.); (B.L.); (S.S.); (R.D.R.); (D.P.); (V.D.G.); (G.S.)
| | - Gilda Cuzzi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.A.); (G.C.); (A.S.); (V.V.)
| | - Andrea Salmi
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.A.); (G.C.); (A.S.); (V.V.)
| | - Valentina Vanini
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.A.); (G.C.); (A.S.); (V.V.)
- Unità Operativa Semplice (UOS) Professioni Sanitarie Tecniche, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy
| | - Fabrizio Maggi
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (F.M.); (S.M.); (G.M.)
| | - Silvia Meschi
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (F.M.); (S.M.); (G.M.)
| | - Giulia Matusali
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (F.M.); (S.M.); (G.M.)
| | - Stefania Notari
- Laboratory of Cellular Immunology and Clinical Pharmacology, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (S.N.); (C.A.)
| | - Chiara Agrati
- Laboratory of Cellular Immunology and Clinical Pharmacology, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (S.N.); (C.A.)
- Department of Pediatric Hematology and Oncology, Bambino Gesù Pediatric Hospital, 00152 Rome, Italy
| | - Simonetta Salemi
- Department of Clinical and Molecular Medicine, “Sapienza” University, S. Andrea University Hospital, 00189 Rome, Italy; (A.P.-D.); (B.L.); (S.S.); (R.D.R.); (D.P.); (V.D.G.); (G.S.)
| | - Roberta Di Rosa
- Department of Clinical and Molecular Medicine, “Sapienza” University, S. Andrea University Hospital, 00189 Rome, Italy; (A.P.-D.); (B.L.); (S.S.); (R.D.R.); (D.P.); (V.D.G.); (G.S.)
| | - Damiano Passarini
- Department of Clinical and Molecular Medicine, “Sapienza” University, S. Andrea University Hospital, 00189 Rome, Italy; (A.P.-D.); (B.L.); (S.S.); (R.D.R.); (D.P.); (V.D.G.); (G.S.)
| | - Valeria Di Gioia
- Department of Clinical and Molecular Medicine, “Sapienza” University, S. Andrea University Hospital, 00189 Rome, Italy; (A.P.-D.); (B.L.); (S.S.); (R.D.R.); (D.P.); (V.D.G.); (G.S.)
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, “Sapienza” University, S. Andrea University Hospital, 00189 Rome, Italy; (A.P.-D.); (B.L.); (S.S.); (R.D.R.); (D.P.); (V.D.G.); (G.S.)
| | - Fabrizio Conti
- Reumatologia, Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, “Sapienza” Università di Roma, 00161 Rome, Italy; (F.C.); (F.R.S.)
| | - Francesca Romana Spinelli
- Reumatologia, Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, “Sapienza” Università di Roma, 00161 Rome, Italy; (F.C.); (F.R.S.)
| | - Angela Corpolongo
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.C.); (E.N.)
| | - Maria Sole Chimenti
- Rheumatology, Allergology and Clinical Immunology, Department of ‘Medicina dei Sistemi’, University of Rome ‘Tor Vergata’, 00133 Rome, Italy;
| | - Mario Ferraioli
- Department of Rheumatology, San Camillo Hospital, 00152 Rome, Italy; (M.F.); (G.D.S.)
| | | | - Maurizio Benucci
- Rheumatology Unit, S. Giovanni di Dio Hospital, Azienda USL—Toscana Centro, 50122 Florence, Italy; (M.B.); (F.L.G.)
| | - Francesca Li Gobbi
- Rheumatology Unit, S. Giovanni di Dio Hospital, Azienda USL—Toscana Centro, 50122 Florence, Italy; (M.B.); (F.L.G.)
| | - Anna Paola Santoro
- UOC Emerging Infections and Centro di Riferimento AIDS (CRAIDS), National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.P.S.); (A.C.); (V.P.)
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bambino Gesù Children’s Hospital, 00165 Rome, Italy
| | - Andrea Capri
- UOC Emerging Infections and Centro di Riferimento AIDS (CRAIDS), National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.P.S.); (A.C.); (V.P.)
| | - Vincenzo Puro
- UOC Emerging Infections and Centro di Riferimento AIDS (CRAIDS), National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.P.S.); (A.C.); (V.P.)
| | - Emanuele Nicastri
- Clinical Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.C.); (E.N.)
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani—Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00149 Rome, Italy; (A.A.); (G.C.); (A.S.); (V.V.)
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8
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Venkat R, Wallace ZS, Sparks JA. Considerations for Pharmacologic Management of Rheumatoid Arthritis in the COVID-19 Era: a Narrative Review. Curr Rheumatol Rep 2023; 25:236-245. [PMID: 37597102 DOI: 10.1007/s11926-023-01111-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE OF REVIEW To review the impact of disease-modifying antirheumatic drugs (DMARDs) on COVID-19 severity and vaccine immunogenicity and to discuss COVID-19 outcomes in patients with rheumatoid arthritis (RA). RECENT FINDINGS Rituximab is associated with severe COVID-19 and impaired vaccine immunogenicity via its B cell-depleting mechanism. JAK inhibitors and glucocorticoids have been modestly associated with severe COVID-19 and impaired vaccine immunogenicity. TNF inhibitors may have a protective effect against severe COVID-19 and do not appear to affect vaccine immunogenicity. Clinical trials have shown improved seroconversion and antibody titers when methotrexate is held around vaccine doses, but this may yield increased risk of RA flare. Patients with RA are also impacted by DMARD disruption, RA flares, and post-acute sequelae of COVID-19 after COVID-19 infection. Given the risks of COVID-19, rituximab should be used with caution in RA. Holding methotrexate doses around COVID-19 vaccination improves immunogenicity but may increase RA flare risk.
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Affiliation(s)
| | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Clinical Epidemiology Program, Mongan Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeffrey A Sparks
- Harvard Medical School, Boston, MA, USA.
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, #6016U, Boston, MA, 02115, USA.
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9
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van Sleen Y, van der Geest KSM, Huckriede ALW, van Baarle D, Brouwer E. Effect of DMARDs on the immunogenicity of vaccines. Nat Rev Rheumatol 2023; 19:560-575. [PMID: 37438402 DOI: 10.1038/s41584-023-00992-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/14/2023]
Abstract
Vaccines are important for protecting individuals at increased risk of severe infections, including patients undergoing DMARD therapy. However, DMARD therapy can also compromise the immune system, leading to impaired responses to vaccination. This Review focuses on the impact of DMARDs on influenza and SARS-CoV-2 vaccinations, as such vaccines have been investigated most thoroughly. Various data suggest that B cell depletion therapy, mycophenolate mofetil, cyclophosphamide, azathioprine and abatacept substantially reduce the immunogenicity of these vaccines. However, the effects of glucocorticoids, methotrexate, TNF inhibitors and JAK inhibitors on vaccine responses remain unclear and could depend on the dosage and type of vaccination. Vaccination is aimed at initiating robust humoral and cellular vaccine responses, which requires efficient interactions between antigen-presenting cells, T cells and B cells. DMARDs impair these cells in different ways and to different degrees, such as the prevention of antigen-presenting cell maturation, alteration of T cell differentiation and selective inhibition of B cell subsets, thus inhibiting processes that are necessary for an effective vaccine response. Innovative modified vaccination strategies are needed to improve vaccination responses in patients undergoing DMARD therapy and to protect these patients from the severe outcomes of infectious diseases.
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Affiliation(s)
- Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands.
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands
| | - Anke L W Huckriede
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, the Netherlands
| | - Debbie van Baarle
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, the Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands.
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10
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Morel J. Infection prevention and vaccination in the rheumatic diseases. Joint Bone Spine 2023; 90:105568. [PMID: 36990142 DOI: 10.1016/j.jbspin.2023.105568] [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] [Accepted: 07/05/2022] [Indexed: 03/29/2023]
Abstract
Patients with chronic inflammatory rheumatisms (CIR) have a higher risk of infections compared to healthy subjects. Viral and bacterial pneumonia are the most frequent infections observed in CIR with targeted disease modifying anti-rheumatic drugs (DMARDs). Moreover, drugs used to treat CIR (especially biologic and synthetic targeted DMARDs) increase the risk of infection and expose CIR patients to opportunistic infections such as tuberculosis reactivation. To limit the risk of infection, the risk-benefit ratio should be evaluated for each patient based on their characteristics and comorbidities. To prevent infections, an initial pre-treatment work-up must be performed, especially before the initiation of conventional synthetic DMARDs or biological and synthetic targeted DMARDs. This pre-treatment assessment includes the case history, laboratory and radiology findings as well. The physician must make sure a patient's vaccinations are up-to-date. The vaccines recommended for patients with CIR being treated with conventional synthetic DMARDs, bDMARDs, tsDMARDs and/or steroids should be given. Patient education is also very important. During workshops, they learn how to manage their drug treatments in at-risk situations and learn which symptoms require treatment discontinuation.
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Affiliation(s)
- Jacques Morel
- Rheumatology Department, CHU and University of Montpellier, PhyMedExp, Inserm, CNRS, Montpellier, France.
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11
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Wroński J, Ciechomska M, Kuca-Warnawin E. Impact of methotrexate treatment on vaccines immunogenicity in adult rheumatological patients - Lessons learned from the COVID-19 pandemic. Biomed Pharmacother 2023; 165:115254. [PMID: 37542854 DOI: 10.1016/j.biopha.2023.115254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023] Open
Abstract
Despite the development of new biological and synthetic targeted therapies, methotrexate remains one of the most commonly used immunomodulatory drugs in rheumatology. However, its effect on the immunogenicity of vaccines has been studied only to a limited extent until recently, resulting in the lack of clear guidelines on the use of methotrexate during vaccination. Significant progress was made during the COVID-19 pandemic due to the dynamic development of research on vaccines, including patients with autoimmune inflammatory rheumatic diseases. In the following literature review, we present a summary of what we know so far on the impact of methotrexate on post-vaccination response in adult rheumatology patients, taking into account the lessons learned from the COVID-19 pandemic. Studies on the effect of methotrexate on the immunogenicity of influenza, pneumococcal, herpes zoster, tetanus/diphtheria/pertussis, hepatitis A, yellow fever, and COVID-19 vaccines are described in detail, including the effect of methotrexate on the humoral and cellular response of individual vaccines. The available evidence for recommendations for withholding methotrexate in the post-vaccination period is presented. Lastly, an overview of potential immunological mechanisms through which MTX modulates the immunogenicity of vaccinations is also provided.
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Affiliation(s)
- Jakub Wroński
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland.
| | - Marzena Ciechomska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
| | - Ewa Kuca-Warnawin
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
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Al-Haideri MT, Mannani R, Kaboli R, Gharebakhshi F, Darvishzadehdeldari S, Tahmasebi S, Faramarzi F, Cotrina-Aliaga JC, Khorasani S, Alimohammadi M, Darvishi M, Akhavan-Sigari R. The effects of methotrexate on the immune responses to the COVID-19 vaccines in the patients with immune-mediated inflammatory disease: A systematic review of clinical evidence. Transpl Immunol 2023; 79:101858. [PMID: 37236514 PMCID: PMC10205646 DOI: 10.1016/j.trim.2023.101858] [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: 09/19/2022] [Revised: 05/01/2023] [Accepted: 05/20/2023] [Indexed: 05/28/2023]
Abstract
COVID-19 vaccines exhibit high levels of immunogenicity in the overall population. Data on the effects of immunomodulators on the consequences of COVID-19 in patients with Immune-mediated inflammatory diseases (IMIDs) remains scarce. This systematic review aimed to evaluate the immune responses to the COVID-19 vaccines in IMID patients receiving methotrexate (MTX) compared to healthy individuals. A comprehensive literature search was carried out using electronic databases such as PubMed, Web of Science, Scopus, Google Scholar, and Embase up to August 2022 to identify eligible RCTs evaluating the effect of MTX on immune responses in patients with COVID-19. The PRISMA checklist protocol was applied for the quality assessment of the selected trials. Our findings demonstrated that MTX lowered the responses of T cells and antibodies in IMID patients compared to healthy controls. We also discovered that young age (<60 years) was the main parameter influencing the antibody response after vaccination, while MTX had little effect. Following vaccination, MTX-hold and age were considered the main factors influencing the antibody response. In patients older than 60 years of age, the time point of 10 days of MTX discontinuation was critical to boosting the humoral response to anti-SARS-CoV-2 IgG. Because many IMID patients did not have adequate humoral and cellular responses, our findings highlighted the importance of second or booster doses of vaccine and temporary MTX discontinuation. As a result, it implies that individuals with IMIDs should be subjected to more research, particularly humoral and cellular immunity efficiency trials after COVID-19 vaccination, until credible information is achieved.
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Affiliation(s)
| | - Reza Mannani
- Vascular Surgeon, Department of Surgery, Faculty of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | | | - Farshad Gharebakhshi
- Department of Radiology, Imam Hossein Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Safa Tahmasebi
- Student Research Committee, Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Faramarzi
- Department of Immunology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Sahar Khorasani
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Alimohammadi
- Student Research Committee, Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), Department of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran.
| | - Reza Akhavan-Sigari
- Department of Neurosurgery, University Medical Center Tuebingen, Germany; Department of Health Care Management and Clinical Research, Collegium Humanum Warsaw Management University Warsaw, Poland
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Park JK, Lee YJ, Kang EH, Shin K, Kim MJ, Ha YJ, Choi SR, Park JW, Kim MH, Kim JY, Jung JI, Choi Y, Winthrop KL, Lee EB. Effect of the methotrexate discontinuation for 1 versus 2 weeks on vaccine response to seasonal influenza vaccine in rheumatoid arthritis: a noninferiority randomized controlled trial. Arthritis Rheumatol 2023. [PMID: 37410775 DOI: 10.1002/art.42644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Affiliation(s)
- Jin Kyun Park
- Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yun Jong Lee
- Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Eun Ha Kang
- Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Kichul Shin
- Seoul Metropolitan Government-Seoul National University, Boramae Medical Center, Seoul, Republic of Korea
| | - Min Jung Kim
- Seoul Metropolitan Government-Seoul National University, Boramae Medical Center, Seoul, Republic of Korea
| | - You-Jung Ha
- Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Se Rim Choi
- Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Jun Won Park
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Mi Hyeon Kim
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Ju Yeon Kim
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji In Jung
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Yunhee Choi
- Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Eun Bong Lee
- Seoul National University College of Medicine, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
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14
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Lodde GC, Krefting F, Placke JM, Schneider L, Fiedler M, Dittmer U, Becker JC, Hölsken S, Schadendorf D, Ugurel S, Sondermann W. COVID-19 vaccination in psoriasis patients receiving systemic treatment: A prospective single-center study. Front Immunol 2023; 14:1107438. [PMID: 37006279 PMCID: PMC10061348 DOI: 10.3389/fimmu.2023.1107438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/22/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundThe rate of seroconversion after COVID-19 vaccination in patients with moderate to severe psoriasis requiring systemic treatment is poorly understood.ObjectivesThe aim of this prospective single-center cohort study performed between May 2020 and October 2021 was to determine the rate of seroconversion after COVID-19 vaccination in patients under active systemic treatment for moderate to severe psoriasis.MethodsInclusion criteria were systemic treatment for moderate to severe psoriasis, known COVID-19 vaccination status, and repetitive anti-SARS-CoV-2-S IgG serum quantification. The primary outcome was the rate of anti-SARS-CoV-2-S IgG seroconversion after complete COVID-19 vaccination.Results77 patients with a median age of 55.9 years undergoing systemic treatment for moderate to severe psoriasis were included. The majority of patients received interleukin- (n=50, 64.9%) or tumor necrosis factor (TNF)-α inhibitors (n=16, 20.8%) as systemic treatment for psoriasis; nine patients (11.7%) were treated with methotrexate (MTX) monotherapy, and one patient each received dimethyl fumarate (1.3%), respectively apremilast (1.3%). All included patients completed COVID-19 vaccination with two doses over the course of the study. Serum testing revealed that 74 patients (96.1%) showed an anti-SARS-CoV-2-S IgG seroconversion. While all patients on IL-17A, -12 or -12/23 inhibitors (n=50) achieved seroconversion, three of 16 patients (18.8%) receiving MTX and/or a TNF-α inhibitor as main anti-psoriatic treatment did not. At follow-up, none of the patients had developed symptomatic COVID-19 or died from COVID-19.ConclusionsAnti-SARS-CoV-2-S IgG seroconversion rates following COVID-19 vaccination in psoriasis patients under systemic treatment were high. An impaired serological response, however, was observed in patients receiving MTX and/or TNF-α inhibitors, in particular infliximab.
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Affiliation(s)
- Georg Christian Lodde
- Department of Dermatology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
| | - Frederik Krefting
- Department of Dermatology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
| | - Jan-Malte Placke
- Department of Dermatology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
| | - Lea Schneider
- Department of Dermatology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
| | - Melanie Fiedler
- Institute for Virology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
| | - Ulf Dittmer
- Institute for Virology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
| | - Jürgen Christian Becker
- Department of Dermatology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
- Translational Skin Cancer Research (tscr), University of Duisburg/Essen, Essen, Germany
- German Consortium for Translational Cancer Research (DKTK), Partner Site Essen/Düsseldorf, Essen, Germany
| | - Stefanie Hölsken
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
- German Consortium for Translational Cancer Research (DKTK), Partner Site Essen/Düsseldorf, Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
- German Consortium for Translational Cancer Research (DKTK), Partner Site Essen/Düsseldorf, Essen, Germany
| | - Wiebke Sondermann
- Department of Dermatology, University Hospital Essen, University of Duisburg/Essen, Essen, Germany
- *Correspondence: Wiebke Sondermann,
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15
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Mori S, Ueki Y, Ishiwada N. Impact of Janus kinase inhibitors on antibody response to 13-valent pneumococcal conjugate vaccine in patients with rheumatoid arthritis. Mod Rheumatol 2023; 33:312-317. [PMID: 35348759 DOI: 10.1093/mr/roac029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/02/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To evaluate the antibody response to 13-valent pneumococcal conjugate vaccine (PCV13) in patients with rheumatoid arthritis receiving Janus kinase inhibitors (JAKIs). METHODS Fifty-three patients receiving methotrexate (MTX; n = 10), JAKI (n = 20), or MTX + JAKI (n = 23) were vaccinated with PCV13. Serum concentrations of immunoglobulin G (IgG) antibodies to 13 pneumococcal serotype capsular polysaccharides were quantified before and 4-6 weeks after vaccination. Positive antibody response was defined as a 2-fold or more increase in IgG concentrations from prevaccination levels. RESULTS After vaccination, IgG concentrations significantly increased in all treatment groups (P <0.001), but fold increases (postvaccination to prevaccination ratios) were different among treatment groups (9.30 for MTX, 6.36 for JAKI, and 3.46 for combination therapy). Positive antibody response rates were comparable between the MTX group (90%) and the JAKI group (95%) but lower in the MTX + JAKI group (52.2%). In a multivariable logistic regression analysis, the combination therapy was the only factor associated with a reduced antibody response to PCV13. No severe adverse events were observed in any treatment group. CONCLUSION Although JAKIs do not impair PCV13 immunogenicity in rheumatoid arthritis patients, the combination of MTX with JAKI can reduce the antibody response in this patient population.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, National Hospital Organization Kumamoto Saishun Medical Center, Kohshi, Kumamoto, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Sasebo, Nagasaki, Japan
| | - Naruhiko Ishiwada
- Department of Infectious Diseases, Medical Mycology Research Center, Chiba University, Chiba, Japan
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16
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Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, Johnson SR, Imundo LF, Winthrop KL, Arasaratnam RJ, Baden LR, Berard R, Bridges SL, Cheah JTL, Curtis JR, Ferguson PJ, Hakkarinen I, Onel KB, Schultz G, Sivaraman V, Smith BJ, Sparks JA, Vogel TP, Williams EA, Calabrese C, Cunha JS, Fontanarosa J, Gillispie-Taylor MC, Gkrouzman E, Iyer P, Lakin KS, Legge A, Lo MS, Lockwood MM, Sadun RE, Singh N, Sullivan N, Tam H, Turgunbaev M, Turner AS, Reston J. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2023; 75:333-348. [PMID: 36597810 DOI: 10.1002/art.42386] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 10/13/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). METHODS This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation. RESULTS This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence. CONCLUSION Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.
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Affiliation(s)
- Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Lisa F Imundo
- Columbia University Irving Medical Center, New York, New York
| | | | - Reuben J Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
| | - Lindsey R Baden
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roberta Berard
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Karen B Onel
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Vidya Sivaraman
- The Ohio State University and Nationwide Children's Hospital, Columbus
| | | | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joanne S Cunha
- Brown University, Brown Physicians Inc., and Providence Veterans Affairs Medical Center, East Providence, Rhode Island
| | | | | | | | - Priyanka Iyer
- University of California Irvine Medical Center, Orange
| | - Kimberly S Lakin
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Alexandra Legge
- Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mindy S Lo
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Herman Tam
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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17
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Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, Johnson SR, Imundo LF, Winthrop KL, Arasaratnam RJ, Baden LR, Berard R, Bridges SL, Cheah JTL, Curtis JR, Ferguson PJ, Hakkarinen I, Onel KB, Schultz G, Sivaraman V, Smith BJ, Sparks JA, Vogel TP, Williams EA, Calabrese C, Cunha JS, Fontanarosa J, Gillispie-Taylor MC, Gkrouzman E, Iyer P, Lakin KS, Legge A, Lo MS, Lockwood MM, Sadun RE, Singh N, Sullivan N, Tam H, Turgunbaev M, Turner AS, Reston J. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken) 2023; 75:449-464. [PMID: 36597813 DOI: 10.1002/acr.25045] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 10/13/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). METHODS This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation. RESULTS This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence. CONCLUSION Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.
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Affiliation(s)
- Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Lisa F Imundo
- Columbia University Irving Medical Center, New York, New York
| | | | - Reuben J Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
| | - Lindsey R Baden
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roberta Berard
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Karen B Onel
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Vidya Sivaraman
- The Ohio State University and Nationwide Children's Hospital, Columbus
| | | | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joanne S Cunha
- Brown University, Brown Physicians Inc., and Providence Veterans Affairs Medical Center, East Providence, Rhode Island
| | | | | | | | - Priyanka Iyer
- University of California Irvine Medical Center, Orange
| | - Kimberly S Lakin
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Alexandra Legge
- Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mindy S Lo
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Herman Tam
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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18
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Kennedy NA, Janjua M, Chanchlani N, Lin S, Bewshea C, Nice R, McDonald TJ, Auckland C, Harries LW, Davies M, Michell S, Kok KB, Lamb CA, Smith PJ, Hart AL, Pollok RC, Lees CW, Boyton RJ, Altmann DM, Sebastian S, Powell N, Goodhand JR, Ahmad T. Vaccine escape, increased breakthrough and reinfection in infliximab-treated patients with IBD during the Omicron wave of the SARS-CoV-2 pandemic. Gut 2023; 72:295-305. [PMID: 35902214 DOI: 10.1136/gutjnl-2022-327570] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/16/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Antitumour necrosis factor (TNF) drugs impair serological responses following SARS-CoV-2 vaccination. We sought to assess if a third dose of a messenger RNA (mRNA)-based vaccine substantially boosted anti-SARS-CoV-2 antibody responses and protective immunity in infliximab-treated patients with IBD. DESIGN Third dose vaccine induced anti-SARS-CoV-2 spike (anti-S) receptor-binding domain (RBD) antibody responses, breakthrough SARS-CoV-2 infection, reinfection and persistent oropharyngeal carriage in patients with IBD treated with infliximab were compared with a reference cohort treated with vedolizumab from the impaCt of bioLogic therApy on saRs-cov-2 Infection and immuniTY (CLARITY) IBD study. RESULTS Geometric mean (SD) anti-S RBD antibody concentrations increased in both groups following a third dose of an mRNA-based vaccine. However, concentrations were lower in patients treated with infliximab than vedolizumab, irrespective of whether their first two primary vaccine doses were ChAdOx1 nCoV-19 (1856 U/mL (5.2) vs 10 728 U/mL (3.1), p<0.0001) or BNT162b2 vaccines (2164 U/mL (4.1) vs 15 116 U/mL (3.4), p<0.0001). However, no differences in anti-S RBD antibody concentrations were seen following third and fourth doses of an mRNA-based vaccine, irrespective of the combination of primary vaccinations received. Post-third dose, anti-S RBD antibody half-life estimates were shorter in infliximab-treated than vedolizumab-treated patients (37.0 days (95% CI 35.6 to 38.6) vs 52.0 days (95% CI 49.0 to 55.4), p<0.0001).Compared with vedolizumab-treated, infliximab-treated patients were more likely to experience SARS-CoV-2 breakthrough infection (HR 2.23 (95% CI 1.46 to 3.38), p=0.00018) and reinfection (HR 2.10 (95% CI 1.31 to 3.35), p=0.0019), but this effect was uncoupled from third vaccine dose anti-S RBD antibody concentrations. Reinfection occurred predominantly during the Omicron wave and was predicted by SARS-CoV-2 antinucleocapsid concentrations after the initial infection. We did not observe persistent oropharyngeal carriage of SARS-CoV-2. Hospitalisations and deaths were uncommon in both groups. CONCLUSIONS Following a third dose of an mRNA-based vaccine, infliximab was associated with attenuated serological responses and more SARS-CoV-2 breakthrough infection and reinfection which were not predicted by the magnitude of anti-S RBD responses, indicative of vaccine escape by the Omicron variant. TRIAL REGISTRATION NUMBER ISRCTN45176516.
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Affiliation(s)
- Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Malik Janjua
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Neil Chanchlani
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Simeng Lin
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Claire Bewshea
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
- Department of Biochemistry, Exeter Clinical Laboratory International, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Timothy J McDonald
- Department of Biochemistry, Exeter Clinical Laboratory International, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Cressida Auckland
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Lorna W Harries
- Institute of Biomedical and Clinical Sciences, University of Exeter, Exeter, UK
| | - Merlin Davies
- Institute of Biomedical and Clinical Sciences, University of Exeter, Exeter, UK
| | - Stephen Michell
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK
| | - Klaartje B Kok
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
- Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Christopher A Lamb
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Translational & Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Philip J Smith
- Department of Gastroenterology, Royal Liverpool Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ailsa L Hart
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, London, UK
| | - Richard Cg Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
- Institute for Infection & Immunity, St George's University of London, London, UK
| | - Charlie W Lees
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
- Institute of Genetic and Molecular Medicine, University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, London, UK
- Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Daniel M Altmann
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Shaji Sebastian
- IBD Unit, Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - Nicholas Powell
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - James R Goodhand
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
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19
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Park JK, Lee YJ, Shin K, Kang EH, Ha YJ, Park JW, Kim MJ, Kim MH, Choi SR, Jung Y, Lee JH, In Jung J, Kim JY, Winthrop KL, Lee EB. A Multicenter, Prospective, Randomized, Parallel-Group Trial on the Effects of Temporary Methotrexate Discontinuation for One Week Versus Two Weeks on Seasonal Influenza Vaccination in Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2023; 75:171-177. [PMID: 35930728 PMCID: PMC10107245 DOI: 10.1002/art.42318] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/07/2022] [Accepted: 07/26/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This clinical trial was conducted to investigate whether discontinuing methotrexate (MTX) for 1 week after seasonal influenza vaccination is noninferior to discontinuing for 2 weeks after vaccination in patients with rheumatoid arthritis (RA). METHODS In this multicenter, prospective, randomized, parallel-group noninferiority trial, RA patients receiving a stable dose of MTX were randomly assigned at a ratio of 1:1 to discontinue MTX for 1 week or for 2 weeks after they received the quadrivalent 2021-2022 seasonal influenza vaccine containing H1N1, H3N2, B/Yamagata, and B/Victoria strains. The primary outcome measure was the proportion of patients with a satisfactory vaccine response, which was defined as ≥4-fold increase in antibody titers, as determined with the hemagglutination inhibition assay, against ≥2 of the 4 vaccine strains at 4 weeks after vaccination. RESULTS The modified intent-to-treat population included 90 patients in the 1-week MTX hold group and 88 patients in the 2-week MTX hold group. The mean ± SD MTX doses were 12.6 ± 3.4 mg/week in the 1-week MTX hold group and 12.9 ± 3.3 mg/week in the 2-week MTX hold group. The proportion of satisfactory vaccine responses did not differ between the groups (68.9% versus 75.0%; P = 0.364). The rate of seroprotection and the fold increase in antibody titers for each of the 4 influenza antigens were similar between the groups. CONCLUSION A temporary discontinuation of MTX for 1 week after vaccination was noninferior to a discontinuation of MTX for 2 weeks after vaccination, regarding induction of a satisfactory vaccine response to a seasonal influenza vaccine in patients with RA receiving a stable dose of MTX.
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Affiliation(s)
- Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, and Seoul National University Hospital, Seoul, Republic of Korea
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea, and Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Kichul Shin
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Jung Kim
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Mi Hyeon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Se Rim Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Youjin Jung
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ju Ho Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Ji In Jung
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ju Yeon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kevin L Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea, and Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Republic of Korea
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20
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Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Williams EA, Mikuls TR. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 5. Arthritis Rheumatol 2023; 75:E1-E16. [PMID: 36345691 PMCID: PMC9878068 DOI: 10.1002/art.42372] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/02/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the use of COVID-19 vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious diseases specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS Despite a paucity of direct evidence, statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines, including supplemental/booster dosing, in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION These guidance statements are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.
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Affiliation(s)
| | - Sindhu R. Johnson
- Toronto Western HospitalMount Sinai Hospital, and University of TorontoTorontoOntarioCanada
| | - Donald D. Anthony
- Louis Stokes Cleveland VA Medical CenterMetroHealth Medical Center, and Case Western Reserve UniversityClevelandOhio
| | - Reuben J. Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical CenterDallas
| | | | - Anne R. Bass
- Hospital for Special Surgery and Weill Cornell MedicineNew YorkNew York
| | | | | | | | | | | | | | | | - Ted R. Mikuls
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care SystemOmaha
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21
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Tobar-Marcillo M, Guerrero-Solís C, Pool-Valda GO, Irazoque-Palazuelos F, Muñoz-López S. Vaccination against influenza and pneumococus in patients with rheumatoid arthritis. REUMATOLOGIA CLINICA 2023; 19:49-52. [PMID: 35570135 DOI: 10.1016/j.reumae.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/24/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Vaccination against pathogens such as influenza or pneumococcus is widely recommended for patients with rheumatoid arthritis; the prevalence of adherence to these vaccination programmes in Mexico is not known. METHODS A cross-sectional descriptive study was carried out, through the application of a survey to adult patients with a diagnosis of rheumatoid arthritis treated in a tertiary hospital in Mexico City. RESULTS 227 patients were included, vaccination against influenza was found in 31.3% and against pneumococcus in 17.6% of patients, the main reasons for non-compliance with the vaccination schedule were related to ignorance and the recommendation by doctors not to do so. CONCLUSIONS Compliance with the recommended vaccination schedules in the studied population is lower than those reported in other populations. The most important interventions to improve coverage should be aimed at educating both patients and medical personnel.
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Affiliation(s)
- Marco Tobar-Marcillo
- Servicio de Reumatología, Centro Médico Nacional 20 de Noviembre, Mexico City, CDMX, Mexico.
| | - Carlos Guerrero-Solís
- Servicio de Reumatología, Centro Médico Nacional 20 de Noviembre, Mexico City, CDMX, Mexico
| | | | | | - Sandra Muñoz-López
- Servicio de Reumatología, Centro Médico Nacional 20 de Noviembre, Mexico City, CDMX, Mexico
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22
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Seo P, Winthrop K, Sawalha AH, Choi S, Hwang W, Park HA, Lee EB, Park JK. Physicians' Agreement on and Implementation of the 2019 European Alliance of Associations for Rheumatology Vaccination Guideline: An International Survey. JOURNAL OF RHEUMATIC DISEASES 2023; 30:18-25. [PMID: 37476523 PMCID: PMC10351355 DOI: 10.4078/jrd.22.0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 10/03/2022] [Accepted: 10/08/2022] [Indexed: 07/22/2023]
Abstract
Objective To evaluate the perspective of healthcare professionals towards the 2019 European Alliance of Associations for Rheumatology (EULAR) vaccination guideline in patients with autoimmune inflammatory rheumatic diseases (AIIRD). Methods Healthcare professionals who care for patients with AIIRD were invited to participate in an online survey regarding their perspective on the 2019 update of the EULAR recommendations for vaccination in adult patients with AIIRD. Level of agreement and implementation of the 6 overarching principles and 9 recommendations were rated on a 5-point Likert scale (1~5). Results Survey responses of 371 healthcare professionals from Asia (42.2%) and North America (41.6%), Europe (13.8%), and other countries were analyzed. Only 16.3% of participants rated their familiarity with the 2019 EULAR guideline as 5/5 ("very well"). There was a high agreement (≥4/5 rating) with the overarching principles, except for the principles applying to live-attenuated vaccines. There was a high level of agreement with the recommendations regarding influenza and pneumococcal vaccinations; implementation of these recommendations was also high. Participants also reported a high level of agreement with the remaining recommendations but did not routinely implement these recommendations. Conclusion The 2019 update of EULAR recommendations for the vaccination of adult patients with AIIRD is generally thought to be important by healthcare professionals, although implementation of adequate vaccination is often lacking. Better education of healthcare providers may be important to optimize the vaccination coverage for patients with AIIRD.
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Affiliation(s)
- Philip Seo
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA
| | - Amr Hakam Sawalha
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA
| | - Serim Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woochang Hwang
- Department of Pre-Medicine, College of Medicine and Hanyang Institute of Bioscience and Biotechnology, Hanyang University, Seoul, Korea
| | - Hyun Ah Park
- Department of Family Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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23
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The Impact of Immune-Modifying Treatments for Skin Diseases on the Immune Response to COVID-19 Vaccines: a Narrative Review. CURRENT DERMATOLOGY REPORTS 2022; 11:263-288. [PMID: 36310766 PMCID: PMC9592867 DOI: 10.1007/s13671-022-00376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2022] [Indexed: 11/18/2022]
Abstract
Purpose of Review SARS-CoV-2 has had a devastating global effect, with vaccinations being paramount in the public health strategy against COVID-19. Vaccinations have uncoupled infection from adverse COVID-19 outcomes worldwide. While immune-modifying therapies are effective for the management of skin diseases such as psoriasis and atopic dermatitis, these medications also impair protective immune responses. There has been longstanding uncertainty and concern over the impact of immune-modifying therapies on the effectiveness of vaccines; for example, it is well recognised that methotrexate impairs humoral responses to both influenza and pneumococcal vaccines. This narrative review aims to discuss the evidence to date on the impact of immune-modifying therapies on the immune response to COVID-19 vaccines, with a focus on the first two vaccine doses. Recent Findings Individuals receiving immune-modifying therapy are more likely to have attenuated humoral responses to a single dose of COVID-19 vaccine compared to healthy controls; however, this may be improved by a complete course of vaccination. B cell targeted biologics such as rituximab markedly impair the humoral response to both the first and second COVID-19 vaccination. There remains a paucity of data on cellular immune responses, with the few available studies indicating lower responses to two vaccine doses in individuals receiving immune-modifying therapies compared to healthy controls, which may impact the durability of immune responses. Summary Inadequate humoral immune responses to a single dose of vaccine in the context of immune-modifying therapy are improved by a complete course of vaccination. Individuals receiving immune-modifying treatments should be encouraged to take up a complete vaccine course to mitigate their risk against COVID-19. Research in large patient populations on the longevity/kinetics of the complex humoral and cellular response to subsequent vaccine doses, including against newer variants of concern, is warranted, in addition to data on immune correlates of vaccine clinical effectiveness.
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Habermann E, Gieselmann L, Tober-Lau P, Klotsche J, Albach FN, ten Hagen A, Zernicke J, Ahmadov E, Arumahandi de Silva AN, Frommert LM, Kurth F, Sander LE, Burmester GR, Klein F, Biesen R. Pausing methotrexate prevents impairment of Omicron BA.1 and BA.2 neutralisation after COVID-19 booster vaccination. RMD Open 2022; 8:rmdopen-2022-002639. [PMID: 36216410 PMCID: PMC9556747 DOI: 10.1136/rmdopen-2022-002639] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/12/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The level of neutralising capacity against Omicron BA.1 and BA.2 after third COVID-19 vaccination in patients on paused or continuous methotrexate (MTX) therapy is unclear. METHODS In this observational cohort study, neutralising serum activity against SARS-CoV-2 wild-type (Wu01) and variant of concern Omicron BA.1 and BA.2 were assessed by pseudovirus neutralisation assay before, 4 and 12 weeks after mRNA booster immunisation in 50 rheumatic patients on MTX, 26 of whom paused the medication. 44 non-immunosuppressed persons (NIP) served as control group. RESULTS While the neutralising serum activity against SARS-CoV-2 Wu01 and Omicron variants increased 67-73 fold in the NIP after booster vaccination, the serum activity in patients receiving MTX increased only 20-23 fold. Patients who continued MTX treatment during vaccination had significantly lower neutralisation against all variants at weeks 4 and 12 compared with patients who paused MTX and the control group, except for BA.2 at week 12. Patients who paused MTX reached comparably high neutralising capacities as NIP, except for Wu01 at week 12. The duration of the MTX pause after-not before-was associated with a significantly higher neutralisation capacity against all three variants, with an optimal duration at 10 days after vaccination. CONCLUSION Patients pausing MTX after COVID-19 booster showed a similar vaccine response to NIP. Patients who continued MTX demonstrated an impaired response indicating a potentially beneficial second booster vaccination. Our data also suggest that a 1 week MTX break is sufficient if the last administration of MTX occurs 1-3 days before vaccination.
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Affiliation(s)
- Elisa Habermann
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Lutz Gieselmann
- Laboratory of Experimental Immunology, Institute of Virologie, University Hospital Cologne, 50931 Cologne, Germany,Center for Molecular Medicine Cologne (CMMC), University of Cologne, 50931 Cologne, Germany,Partner site Bonn-Cologne, German Centre for Infection Research, 50931 Cologne, Germany
| | - Pinkus Tober-Lau
- Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Jens Klotsche
- Epidemiology Unit, German Rheumatism Research Center, Berlin, Germany
| | - Fredrik Nils Albach
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Alexander ten Hagen
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Jan Zernicke
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Elvin Ahmadov
- Laboratory of Experimental Immunology, Institute of Virologie, University Hospital Cologne, 50931 Cologne, Germany
| | | | - Leonie Maria Frommert
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Florian Kurth
- Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Leif Erik Sander
- Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
| | - Florian Klein
- Laboratory of Experimental Immunology, Institute of Virologie, University Hospital Cologne, 50931 Cologne, Germany,Center for Molecular Medicine Cologne (CMMC), University of Cologne, 50931 Cologne, Germany,Partner site Bonn-Cologne, German Centre for Infection Research, 50931 Cologne, Germany
| | - Robert Biesen
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin Campus Charite Mitte, Berlin, Germany
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Skaria TG, Sreeprakash A, Umesh R, Joseph S, Mohan M, Ahmed S, Mehta P, Oommen SE, Benny J, Paulose A, Paul A, George J, Sukumaran A, Babu SS, Navas S, Vijayan A, Joseph S, Nalianda KK, Narayanan K, Shenoy P. Withholding methotrexate after vaccination with ChAdOx1 nCov19 in patients with rheumatoid or psoriatic arthritis in India (MIVAC I and II): results of two, parallel, assessor-masked, randomised controlled trials. THE LANCET RHEUMATOLOGY 2022; 4:e755-e764. [PMID: 36320825 PMCID: PMC9612848 DOI: 10.1016/s2665-9913(22)00228-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background There is a necessity for an optimal COVID-19 vaccination strategy for vulnerable population groups, including people with autoimmune inflammatory arthritis on immunosuppressants such as methotrexate, which inhibit vaccine-induced immunity against SARS-CoV-2. Thus, we aimed to assess the effects of withholding methotrexate for 2 weeks after each dose of ChAdOx1 nCov-19 (Oxford–AstraZeneca) vaccine (MIVAC I) or only after the second dose of vaccine (MIVAC II) compared with continuation of methotrexate, in terms of post-vaccination antibody titres and disease flare rates. Methods MIVAC I and II were two parallel, independent, assessor-masked, randomised trials. The trials were done at a single centre (Dr Shenoy's Centre for Arthritis and Rheumatism Excellence; Kochi, India) in people with either rheumatoid arthritis or psoriatic arthritis with stable disease activity, who had been on a fixed dose of methotrexate for the preceding 6 weeks. Those with previous COVID-19 or who were positive for anti-SARS-CoV-2 nucleocapsid antibodies were excluded from the trials. People on high-dose corticosteroids and rituximab were also excluded, whereas other disease-modifying antirheumatic drugs were allowed. In MIVAC I, participants were randomly assigned (1:1) to stop methotrexate treatment for 2 weeks after each vaccine dose or to continue methotrexate treatment. In MIVAC II, participants who had continued methotrexate during the first dose of vaccine were randomly assigned (1:1) to withhold methotrexate for 2 weeks after the second dose of vaccine or to continue to take methotrexate. The treating physician was masked to the group assignments. The primary outcome for both MIVAC I and MIVAC II was the titre (absolute value) of anti-receptor binding domain (RBD) antibody measured 4 weeks after the second dose of vaccine. All analyses were done per protocol. The trials were registered with the Clinical Trials Registry- India, number CTRI/2021/07/034639 (MIVAC I) and CTRI/2021/07/035307 (MIVAC II). Findings Between July 6 and Dec 15, 2021, participants were recruited to the trials. In MIVAC I, 250 participants were randomly assigned and 158 completed the study as per the protocol (80 in the methotrexate hold group and 78 in the control group; 148 [94%] were women and 10 [6%] were men). The median post-vaccination antibody titres in the methotrexate hold group were significantly higher compared with the control group (2484·0 IU/mL, IQR 1050·0–4388·8 vs 1147·5 IU/mL, 433·5–2360·3; p=0·0014). In MIVAC II, 178 participants were randomly assigned and 157 completed the study per protocol (76 in the methotrexate hold group and 81 in the control group; 135 [86%] were women and 22 [14%] were men). The methotrexate hold group had higher post-vaccination antibody titres compared with the control group (2553·5 IU/ml, IQR 1792·5–4823·8 vs 990·5, 356·1–2252·5; p<0·0001). There were no reports of any serious adverse events during the trial period. Interpretation Withholding methotrexate after both ChAdOx1 nCov-19 vaccine doses and after only the second dose led to higher anti-RBD antibody titres compared with continuation of methotrexate. However, withholding methotrexate only after the second vaccine dose resulted in a similar humoral response to holding methotrexate after both vaccine doses, without an increased risk of arthritis flares. Hence, interruption of methotrexate during the second dose of ChAdOx1 nCov-19 vaccine appears to be a safe and effective strategy to improve the antibody response in patients with rheumatoid or psoriatic arthritis. Funding Indian Rheumatology Association.
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Affiliation(s)
| | | | | | - Sneha Joseph
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
- Sree Sudheendra Medical Mission, Kochi, India
| | - Manju Mohan
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | - Sakir Ahmed
- Clinical Immunology and Rheumatology Department, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | | | | | - Jannet Benny
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | - Anagha Paulose
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | - Aby Paul
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | - Justin George
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | | | - Sageer S Babu
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | - Safna Navas
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | - Anuroopa Vijayan
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
- Sree Sudheendra Medical Mission, Kochi, India
| | - Sanjana Joseph
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | - Kaveri K Nalianda
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
- Sree Sudheendra Medical Mission, Kochi, India
| | - Krishnan Narayanan
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
- Sree Sudheendra Medical Mission, Kochi, India
| | - Padmanabha Shenoy
- Centre for Arthritis and Rheumatism Excellence, Kochi, India
- Sree Sudheendra Medical Mission, Kochi, India
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Abhishek A, Boyton RJ, Peckham N, McKnight Á, Coates LC, Bluett J, Barber V, Cureton L, Francis A, Appelbe D, Eldridge L, Julier P, Valdes AM, Brooks T, Rombach I, Altmann DM, Nguyen-Van-Tam JS, Williams HC, Cook JA. Effect of a 2-week interruption in methotrexate treatment versus continued treatment on COVID-19 booster vaccine immunity in adults with inflammatory conditions (VROOM study): a randomised, open label, superiority trial. THE LANCET. RESPIRATORY MEDICINE 2022; 10:840-850. [PMID: 35772416 PMCID: PMC9236568 DOI: 10.1016/s2213-2600(22)00186-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Immunosuppressive treatments inhibit vaccine-induced immunity against SARS-CoV-2. We evaluated whether a 2-week interruption of methotrexate treatment immediately after the COVID-19 vaccine booster improved antibody responses against the S1 receptor-binding domain (S1-RBD) of the SARS-CoV-2 spike protein compared with uninterrupted treatment in patients with immune-mediated inflammatory diseases. METHODS We did an open-label, prospective, two-arm, parallel-group, multicentre, randomised, controlled, superiority trial in 26 hospitals in the UK. We recruited adults from rheumatology and dermatology clinics who had been diagnosed with an immune-mediated inflammatory disease (eg, rheumatoid arthritis, psoriasis with or without arthritis, axial spondyloarthritis, atopic dermatitis, polymyalgia rheumatica, and systemic lupus erythematosus) and who were taking low-dose weekly methotrexate (≤25 mg per week) for at least 3 months. Participants also had to have received two primary vaccine doses from the UK COVID-19 vaccination programme. We randomly assigned the participants (1:1), using a centralised validated computer randomisation program, to suspend methotrexate treatment for 2 weeks immediately after their COVID-19 booster (suspend methotrexate group) or to continue treatment as usual (continue methotrexate group). Participants, investigators, clinical research staff, and data analysts were unmasked, while researchers doing the laboratory analyses were masked to group assignment. The primary outcome was S1-RBD antibody titres 4 weeks after receiving the COVID-19 booster vaccine dose, assessed in the intention-to-treat population. This trial is registered with ISRCT, ISRCTN11442263; following the pre-planned interim analysis, recruitment was stopped early. FINDINGS Between Sept 30, 2021 and March 3, 2022, we recruited 340 participants, of whom 254 were included in the interim analysis and had been randomly assigned to one of the two groups: 127 in the continue methotrexate group and 127 in the suspend methotrexate group. Their mean age was 59·1 years, 155 (61%) were female, 130 (51%) had rheumatoid arthritis, and 86 (34%) had psoriasis with or without arthritis. After 4 weeks, the geometric mean S1-RBD antibody titre was 22 750 U/mL (95% CI 19 314-26 796) in the suspend methotrexate group and 10 798 U/mL (8970-12 997) in the continue methotrexate group, with a geometric mean ratio (GMR) of 2·19 (95% CI 1·57-3·04; p<0·0001; mixed-effects model). The increased antibody response in the suspend methotrexate group was consistent across methotrexate dose, administration route, type of immune-mediated inflammatory disease, age, primary vaccination platform, and history of SARS-CoV-2 infection. There were no intervention-related serious adverse events. INTERPRETATION A 2-week interruption of methotrexate treatment for people with immune-mediated inflammatory diseases resulted in enhanced boosting of antibody responses after COVID-19 vaccination. This intervention is simple, low-cost, and easy to implement, and could potentially translate to increased vaccine efficacy and duration of protection for susceptible groups. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, London, UK; Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, UK
| | - Nicholas Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Biomedical Research Centre, Oxford, UK
| | - James Bluett
- National Institute of Health and Care Research, Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Vicki Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Patrick Julier
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | | | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Daniel M Altmann
- Department of Inflammation and Immunology, Imperial College London, London, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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Andreica I, Blazquez-Navarro A, Sokolar J, Anft M, Kiltz U, Pfaender S, Vidal Blanco E, Westhoff T, Babel N, Stervbo U, Baraliakos X. Different humoral but similar cellular responses of patients with autoimmune inflammatory rheumatic diseases under disease-modifying antirheumatic drugs after COVID-19 vaccination. RMD Open 2022; 8:rmdopen-2022-002293. [PMID: 36104115 PMCID: PMC9475968 DOI: 10.1136/rmdopen-2022-002293] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/18/2022] [Indexed: 11/12/2022] Open
Abstract
Objectives The effect of different modes of immunosuppressive therapy in autoimmune inflammatory rheumatic diseases (AIRDs) remains unclear. We investigated the impact of immunosuppressive therapies on humoral and cellular responses after two-dose vaccination. Methods Patients with rheumatoid arthritis, axial spondyloarthritis or psoriatic arthritis treated with TNFi, IL-17i (biological disease-modifying antirheumatic drugs, b-DMARDs), Janus-kinase inhibitors (JAKi) (targeted synthetic, ts-DMARD) or methotrexate (MTX) (conventional synthetic DMARD, csDMARD) alone or in combination were included. Almost all patients received mRNA-based vaccine, four patients had a heterologous scheme. Neutralising capacity and levels of IgG against SARS-CoV-2 spike-protein were evaluated together with quantification of activation markers on T-cells and their production of key cytokines 4 weeks after first and second vaccination. Results 92 patients were included, median age 50 years, 50% female, 33.7% receiving TNFi, 26.1% IL-17i, 26.1% JAKi (all alone or in combination with MTX), 14.1% received MTX only. Although after first vaccination only 37.8% patients presented neutralising antibodies, the majority (94.5%) developed these after the second vaccination. Patients on IL17i developed the highest titres compared with the other modes of action. Co-administration of MTX led to lower, even if not significant, titres compared with b/tsDMARD monotherapy. Neutralising antibodies correlated well with IgG titres against SARS-CoV-2 spike-protein. T-cell immunity revealed similar frequencies of activated T-cells and cytokine profiles across therapies. Conclusions Even after insufficient seroconversion for neutralising antibodies and IgG against SARS-CoV-2 spike-protein in patients with AIRDs on different medications, a second vaccination covered almost all patients regardless of DMARDs therapy, with better outcomes in those on IL-17i. However, no difference of bDMARD/tsDMARD or csDMARD therapy was found on the cellular immune response.
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Affiliation(s)
- Ioana Andreica
- Ruhr-Universität Bochum, Bochum, Germany .,Rheumazentrum Ruhrgebiet, Herne, Germany
| | - Arturo Blazquez-Navarro
- Humboldt-Universität zu Berlin, Berlin Center for Advanced Therapies (BeCAT), Charite Universitätsmedizin, Berlin, Germany
| | - Jan Sokolar
- Ruhr-Universität Bochum, Bochum, Germany.,Rheumazentrum Ruhrgebiet, Herne, Germany
| | - Moritz Anft
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical department I, Marien Hospital, University Hospital of the Ruhr-Universität Bochum, Herne, Germany
| | - Uta Kiltz
- Ruhr-Universität Bochum, Bochum, Germany.,Rheumazentrum Ruhrgebiet, Herne, Germany
| | - Stephanie Pfaender
- Department of Molecular and Medical Virology, Ruhr-Universität, Bochum, Germany
| | - Elena Vidal Blanco
- Department of Molecular and Medical Virology, Ruhr-Universität, Bochum, Germany
| | - Timm Westhoff
- Ruhr-Universität Bochum, Bochum, Germany.,Medical Department I, Marien Hospital Herne,University Hospital of the Ruhr-Universität Bochum, Herne, Germany
| | - Nina Babel
- Humboldt-Universität zu Berlin, Berlin Center for Advanced Therapies (BeCAT), Charite Universitätsmedizin, Berlin, Germany.,Center for Translational Medicine and Immune Diagnostics Laboratory, Medical department I, Marien Hospital, University Hospital of the Ruhr-Universität Bochum, Herne, Germany
| | - Ulrik Stervbo
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical department I, Marien Hospital, University Hospital of the Ruhr-Universität Bochum, Herne, Germany
| | - Xenofon Baraliakos
- Ruhr-Universität Bochum, Bochum, Germany.,Rheumazentrum Ruhrgebiet, Herne, Germany
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Coates LC, Abhishek A. Suspending methotrexate for 2 weeks after COVID-19 vaccination. THE LANCET RHEUMATOLOGY 2022; 4:e740-e741. [PMID: 36118533 PMCID: PMC9467517 DOI: 10.1016/s2665-9913(22)00265-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Methotrexate Treatment Suppresses Monocytes in Nonresponders to Pneumococcal Conjugate Vaccine in Rheumatoid Arthritis Patients. J Immunol Res 2022; 2022:7561661. [PMID: 35935581 PMCID: PMC9352482 DOI: 10.1155/2022/7561661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/05/2022] [Indexed: 12/29/2022] Open
Abstract
Patients with rheumatoid arthritis (RA) have an increased risk of infections; therefore, immunization against vaccine-preventable diseases is important. Methotrexate (MTX) impairs the antibody response to pneumococcal conjugate vaccine (PCV) in patients with arthritis, and the underlying mechanism is largely unknown. Here, we investigate the potential role of the innate immune system in the faltering antibody response following PCV vaccination in RA patients treated with MTX. Phenotypes of circulating granulocytes and monocytes were analyzed in 11 RA patients treated with MTX, 13 RA patients without disease-modifying antirheumatic drug treatment (0DMARD), and 13 healthy controls (HC). Peripheral blood samples were collected before and 7 days after vaccination. In addition, the MTX group was sampled before initiating treatment. Frequencies of granulocyte and monocyte subsets were determined using flow cytometry. Serotype-specific IgG were quantified using a multiplex bead assay, pre- and 4-6 weeks after vaccination. At baseline, no differences in granulocyte and monocyte frequencies were observed between the groups. Within the MTX group, the frequency of basophils increased during treatment and was higher compared to the HC and 0DMARD groups at the prevaccination time point. MTX patients were categorized into responders and nonresponders according to the antibody response. Before initiation of MTX, there were no differences in granulocyte and monocyte frequencies between the two subgroups. However, following 6-12 weeks of MTX treatment, both the frequency and concentration of monocytes were lower in PCV nonresponders compared to responders, and the difference in monocyte frequency remained after vaccination. In conclusion, the suppressive effect of MTX on monocyte concentration and frequency could act as a biomarker to identify nonresponders to PCV vaccination.
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Effectiveness of delayed second dose of AZD1222 vaccine in patients with autoimmune rheumatic disease. Clin Rheumatol 2022; 41:3537-3542. [PMID: 35760938 PMCID: PMC9244552 DOI: 10.1007/s10067-022-06247-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 01/05/2023]
Abstract
There is paucity of data on extended dosing interval between two doses of AZD1222 (AstraZeneca) in patients with Autoimmune Rheumatic Diseases (AIRD). We aimed to study the humoral response and rate of breakthrough infections between the two groups who had received the second dose of vaccine at 4 weeks (Group 1) and 10–14 weeks (Group 2). From established cohort [COVID-19 vaccination cohort from CARE(CVCC)] of vaccinated patients with AIRD, those who had received AZD1222 were included and divided into two groups. Anti-Receptor Binding Domain (RBD) antibodies (IU/ml) were measured 1 month after the second dose. Its predictors and rate of breakthrough infections were studied. Four hundred ninety-five patients with AIRD were included in this study. Group 2 had higher anti-RBD antibody titres [1310.6 (±977.8) and [736 (±864.7), p = 0.0001. On univariate analysis, presence of Diabetes Mellitus; use of Methotrexate, Sulfasalazine, and Mycophenolate Mofetil; and vaccine interval were significantly associated with anti-RBD antibodies. Diabetes Mellitus and vaccine interval were independent predictors on multivariate analysis. Breakthrough infections were higher in Group 1 numerically on survival analysis but the difference was not significant (7.5% and 4.5%; log rank test: p = 0.25). In conclusion, increasing the gap between doses of the AZD1222 vaccine from 4 week to 10–14 weeks was found to be more beneficial in terms of antibody response in patients with AIRD. There was a trend towards higher breakthrough infections in the short interval group, supporting the antibody data.Key Points • There is paucity of data on effectiveness of increased dosing interval from 4-6 to 10-14 weeks for AZD1222 in patients with AIRDs • We observed a better humoral response with increased dosing interval with the interval and Diabetes Mellitus being independent predictors of the anti-RBD antibody levels • Breakthrough infections were numerically higher in the short interval group but the difference wasn't significant |
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Arumahandi de Silva AN, Frommert LM, Albach FN, Klotsche J, Scholz V, Jeworowski LM, Schwarz T, Ten Hagen A, Zernicke J, Corman VM, Drosten C, Burmester GR, Biesen R. Pausing methotrexate improves immunogenicity of COVID-19 vaccination in elderly patients with rheumatic diseases. Ann Rheum Dis 2022; 81:881-888. [PMID: 35288376 PMCID: PMC9120396 DOI: 10.1136/annrheumdis-2021-221876] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/24/2022] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Amanthi Nadira Arumahandi de Silva
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Leonie Maria Frommert
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Fredrik N Albach
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Jens Klotsche
- Epidemiology Unit, German Rheumatism Research Center Berlin - a Leibniz Institute (DRFZ), Berlin, Germany
| | - Veronika Scholz
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Lara Maria Jeworowski
- Institute of Virology, Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, and German Centre for Infection Research (DZIF), Associated Partner Site, Berlin, Germany
| | - Tatjana Schwarz
- Institute of Virology, Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, and German Centre for Infection Research (DZIF), Associated Partner Site, Berlin, Germany
| | - Alexander Ten Hagen
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Jan Zernicke
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Victor Max Corman
- Institute of Virology, Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, and German Centre for Infection Research (DZIF), Associated Partner Site, Berlin, Germany
- Labor Berlin, Charité - Vivantes GmbH, Berlin, Germany
| | - Christian Drosten
- Institute of Virology, Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, and German Centre for Infection Research (DZIF), Associated Partner Site, Berlin, Germany
| | - Gerd-Rüdiger Burmester
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Robert Biesen
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
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De Santis M, Motta F, Isailovic N, Clementi M, Criscuolo E, Clementi N, Tonutti A, Rodolfi S, Barone E, Colapietro F, Ceribelli A, Vecellio M, Luciano N, Guidelli G, Caprioli M, Rezk C, Canziani L, Azzolini E, Germagnoli L, Mancini N, Lleo A, Selmi C. Dose-Dependent Impairment of the Immune Response to the Moderna-1273 mRNA Vaccine by Mycophenolate Mofetil in Patients with Rheumatic and Autoimmune Liver Diseases. Vaccines (Basel) 2022; 10:vaccines10050801. [PMID: 35632557 PMCID: PMC9144166 DOI: 10.3390/vaccines10050801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/14/2022] [Accepted: 05/15/2022] [Indexed: 12/12/2022] Open
Abstract
The purpose of this study was to evaluate the efficacy and safety of the Moderna-1273 mRNA vaccine for SARS-CoV-2 in patients with immune-mediated diseases under different treatments. Anti-trimeric spike protein antibodies were tested in 287 patients with rheumatic or autoimmune diseases (10% receiving mycophenolate mofetil, 15% low-dose glucocorticoids, 21% methotrexate, and 58% biologic/targeted synthetic drugs) at baseline and in 219 (76%) 4 weeks after the second Moderna-1273 mRNA vaccine dose. Family members or caretakers were enrolled as the controls. The neutralizing serum activity against SARS-CoV-2-G614, alpha, and beta variants in vitro and the cytotoxic T cell response to SARS-CoV-2 peptides were determined in a subgroup of patients and controls. Anti-SARS-CoV-2 antibody development, i.e., seroconversion, was observed in 69% of the mycophenolate-treated patients compared to 100% of both the patients taking other treatments and the controls (p < 0.0001). A dose-dependent impairment of the humoral response was observed in the mycophenolate-treated patients. A daily dose of >1 g at vaccination was a significant risk factor for non-seroconversion (ROC AUC 0.89, 95% CI 0.80−98, p < 0.0001). Moreover, in the seroconverted patients, a daily dose of >1 g of mycophenolate was associated with significantly lower anti-SARS-CoV-2 antibody titers, showing slightly reduced neutralizing serum activity but a comparable cytotoxic response compared to other immunosuppressants. In non-seroconverted patients treated with mycophenolate at a daily dose of >1 g, the cytotoxic activity elicited by viral peptides was also impaired. Mycophenolate treatment affects the Moderna-1273 mRNA vaccine immunogenicity in a dose-dependent manner, independent of rheumatological disease.
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Affiliation(s)
- Maria De Santis
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
| | - Francesca Motta
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
| | - Natasa Isailovic
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
| | - Massimo Clementi
- Laboratory of Medical Microbiology and Virology, University Vita-Salute San Raffaele, 20132 Milan, Italy; (M.C.); (N.C.); (N.M.)
- IRCCS San Raffaele Hospital, 20132 Milan, Italy;
| | | | - Nicola Clementi
- Laboratory of Medical Microbiology and Virology, University Vita-Salute San Raffaele, 20132 Milan, Italy; (M.C.); (N.C.); (N.M.)
- IRCCS San Raffaele Hospital, 20132 Milan, Italy;
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy
| | - Stefano Rodolfi
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy
| | - Elisa Barone
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy
| | - Francesca Colapietro
- Division of Internal Medicine and Liver Disease, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy;
| | - Angela Ceribelli
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
| | - Matteo Vecellio
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
| | - Nicoletta Luciano
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
| | - Giacomo Guidelli
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
| | - Marta Caprioli
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
| | - Clara Rezk
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
| | - Lorenzo Canziani
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
| | - Elena Azzolini
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
- Medical Direction, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy;
| | - Luca Germagnoli
- Diagnostic Laboratory, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy;
| | - Nicasio Mancini
- Laboratory of Medical Microbiology and Virology, University Vita-Salute San Raffaele, 20132 Milan, Italy; (M.C.); (N.C.); (N.M.)
- IRCCS San Raffaele Hospital, 20132 Milan, Italy;
| | - Ana Lleo
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
- Division of Internal Medicine and Liver Disease, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy;
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (M.D.S.); (F.M.); (N.I.); (A.C.); (M.V.); (N.L.); (G.G.); (M.C.); (L.C.)
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; (A.T.); (S.R.); (E.B.); (C.R.); (A.L.)
- Correspondence: ; Tel.: +39-028-2245-118
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Abhishek A, Boyton RJ, McKnight Á, Coates L, Bluett J, Barber VS, Cureton L, Francis A, Appelbe D, Eldridge L, Julier P, Peckham N, Valdes AM, Rombach I, Altmann DM, Nguyen-Van-Tam J, Williams HC, Cook JA. Effects of temporarily suspending low-dose methotrexate treatment for 2 weeks after SARS-CoV-2 vaccine booster on vaccine response in immunosuppressed adults with inflammatory conditions: protocol for a multicentre randomised controlled trial and nested mechanistic substudy (Vaccine Response On/Off Methotrexate (VROOM) study). BMJ Open 2022; 12:e062599. [PMID: 35504634 PMCID: PMC9066090 DOI: 10.1136/bmjopen-2022-062599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION It is unknown if a temporary break in long-term immune-suppressive treatment after vaccination against COVID-19 improves vaccine response. The objective of this study was to evaluate if a 2-week interruption in low-dose weekly methotrexate treatment after SARS-CoV-2 vaccine boosters enhances the immune response compared with continuing treatment in adults with autoimmune inflammatory conditions. METHODS AND ANALYSIS An open-label, pragmatic, prospective, parallel group, randomised controlled superiority trial with internal feasibility assessment and nested mechanistic substudy will be conducted in rheumatology and dermatology clinics in approximately 25 UK hospitals. The sample size is 560, randomised 1:1 to intervention and usual care arms. The main outcome measure is anti-spike receptor-binding domain (RBD) antibody level, collected at prebooster (baseline), 4 weeks (primary outcome) and 12 weeks (secondary outcome) post booster vaccination. Other secondary outcome measures are patient global assessments of disease activity, disease flares and their treatment, EuroQol 5- dimention 5-level (EQ-5D-5L), self-reported adherence with advice to interrupt or continue methotrexate, neutralising antibody titre against SARS-CoV-2 (mechanistic substudy) and oral methotrexate biochemical adherence (mechanistic substudy). Analysis of B-cell memory and T-cell responses at baseline and weeks 4 and 12 will be investigated subject to obtaining additional funding. The principal analysis will be performed on the groups as randomised (ie, intention to treat). The difference between the study arms in anti-spike RBD antibody level will be estimated using mixed effects model, allowing for repeated measures clustered within participants. The models will be adjusted for randomisation factors and prior SARS-CoV-2 infection status. ETHICS AND DISSEMINATION This study was approved by the Leeds West Research Ethics Committee and Health Research Authority (REC reference: 21/HRA/3483, IRAS 303827). Participants will be required to give written informed consent before taking part in the trial. Dissemination will be via peer review publications, newsletters and conferences. Results will be communicated to policymakers. TRIAL REGISTRATION NUMBER ISRCTN11442263.
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Affiliation(s)
| | - R J Boyton
- Department of Infectious Diseases, Imperial College London, London, UK
- Lung Division, Royal Brompton and Harefield Hospitals, London, London
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | | | - James Bluett
- Manchester Academic Health Science Centre, Manchester, UK
- The University of Manchester, Manchester, UK
| | - Vicki S Barber
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Lucy Cureton
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Anne Francis
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Duncan Appelbe
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Lucy Eldridge
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Patrick Julier
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Nicholas Peckham
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | - Ines Rombach
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Daniel M Altmann
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Jonathan Alistair Cook
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
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Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Williams EA, Mikuls TR. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 4. Arthritis Rheumatol 2022; 74:e21-e36. [PMID: 35474640 PMCID: PMC9082483 DOI: 10.1002/art.42109] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/02/2022] [Accepted: 03/02/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the use of COVID-19 vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS Despite a paucity of direct evidence, statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines, including supplemental/booster dosing, in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION These guidance statements are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.
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Affiliation(s)
| | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Donald D Anthony
- Louis Stokes Cleveland VA Medical Center, MetroHealth Medical Center, and Case Western Reserve University, Cleveland, Ohio
| | - Reuben J Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
| | | | - Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | | | - Ted R Mikuls
- University of Nebraska Medical Center and VA Nebraska-Western, Iowa Health Care System, Omaha
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Tran AP, Tassone D, Nossent J, Ding NS. Antibody response to the COVID-19 ChAdOx1nCov-19 and BNT162b vaccines after temporary suspension of DMARD therapy in immune-mediated inflammatory disease (RESCUE). RMD Open 2022; 8:e002301. [PMID: 35577478 PMCID: PMC9114315 DOI: 10.1136/rmdopen-2022-002301] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/06/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To assess the antibody response to disease-modifying antirheumatic drug (DMARD) therapy after the first and second dose of the ChAdOx1nCov-19 (AstraZeneca (AZ)) and BNT162b (Pfizer) vaccines in patients with immune-mediated inflammatory disease (IMID) compared with controls and if withholding therapy following the first vaccination dose has any effect on seroconversion and SARS-CoV-2 antibody (Ab) levels. METHODS A multicentre three-arm randomised controlled trial compared the immunogenicity of the Pfizer and AZ vaccines in adult patients on conventional synthetic (csDMARD), biologic (bDMARD) or targeted synthetic (tsDMARD) therapy for IMID (n=181) with a control group (n=59). Patients were randomised to continue or withhold DMARD therapy for 1-2 weeks post first dose vaccination only. Serum SARS-CoV-2 IgG detection (IgG ≥1.0 U/mL) and titres against the S1/S2 proteins were measured at baseline, 3-4 weeks post first vaccination and 4 weeks post second vaccination. RESULTS AZ vaccination was given to 47.5%, 41.5% and 52.5% in the continue, withhold and control groups, respectively while Pfizer vaccination was given to 52.5%, 58.5% and 47.5% among the continue, withhold and control groups, respectively. Seroconversion rates following the first dose in the AZ and Pfizer groups were only 27.3% vs 79.2% (p=0.000) and 64.58% vs 100% (p=0.000), respectively in the IMID groups who continued therapy compared with the AZ and Pfizer controls, respectively. Withholding DMARD therapy following the first vaccination dose resulted in higher seroconversion to 67.7% and 84.1% in the AZ and Pfizer groups, respectively. Following the second AZ and Pfizer vaccinations when all DMARDs were continued, despite a slightly lower seroconversion rate (83.7% vs 100%, p=0.000 and 95.9% vs 100%, p=0.413), respectively, the mean SARS-CoV2 IgG Ab titres were not significantly different in the csDMARD and bDMARD groups compared with the controls regardless of hold while it was significantly lower in patients taking tsDMARD (12.88 vs 79.49 U/mL, p=0.000). CONCLUSIONS Following the first vaccination dose, antibody responses were lower in IMID on DMARD therapy, however the final responses were excellent regardless of hold with the exception of the tsDMARD group where withholding therapy is recommended. At least 2 vaccinations are therefore recommended preferably with an messenger RNA vaccine. TRIAL REGISTRATION NUMBER ANZCTR: 12621000661875.
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Affiliation(s)
- Ai Phuong Tran
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia
- Department of Rheumatology, St John of God Murdoch, Perth, Western Australia, Australia
| | - Daniel Tassone
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Johannes Nossent
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia
- Department of Rheumatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Nik Sheng Ding
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Gastroenterology Department, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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Alsaed O, AL Emadi S, Satti E, Muthanna B, Akkam Veettil SF, Ashour H, Chandra P, Alkuwari EA, Coyle P. Humoral Response of Patients With Autoimmune Rheumatic Disease to BNT162b2 Vaccine: A Retrospective Comparative Study. Cureus 2022; 14:e24585. [PMID: 35651432 PMCID: PMC9138718 DOI: 10.7759/cureus.24585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/05/2022] Open
Abstract
Objective The effectiveness and safety of SARS-CoV-2 vaccines in patients with autoimmune rheumatic diseases (ARDs) treated with immunomodulators remain uncertain. Therefore, this study aimed to evaluate whether the humoral immune response to the BNT162b2 vaccine differs between patients without and with ARDs treated with immunomodulators. Methods We retrospectively reviewed 3208 electronic medical records from the database of the Hamad Medical Corporation (HMC) outpatient rheumatology clinics to capture patients with ARDs and control patients without autoimmune inflammatory diseases. All patients who were SARS-CoV-2 infection-naïve, had received two doses of BNT162b2 vaccination, and had been serologically tested using Elecsys® anti-SARS-CoV-2 S immunoassays (Roche Holdings AG, Basel, Switzerland), were included in the analysis. Patients with ARD were classified into six subgroups according to the received ARD immunomodulators: methotrexate monotherapy (MTXM), a combination of conventional synthetic disease-modifying antirheumatic drugs (Cs-DMARDs), tumor necrosis factor inhibitor (TNF-i), rituximab, interleukin-6 inhibitor (IL6-i), and Janus kinase inhibitor (JAK-i). Samples with an anti-SARS-CoV-2 S titer of <0.8 and <132 binding antibody unit (BAU)/mL were defined as negative and poor seroconversion, respectively. The overall mean of anti-SARS-CoV-2 S titer and its level at <0.8 and <132 were compared between the six subgroups of patients with ARD and the controls by performing an unpaired t-test and Chi-squared or Fisher's exact test as appropriate. Results The mean (SD) age of 110 patients with ARDs and 20 controls was 47.1 (12) and 59.3 (8.9) years (P < 0.001), respectively, and women predominated both groups (60% vs. 75%, P = 0.20). The most frequently prescribed Cs-DMARDs was methotrexate in 50 (45.5%) patients, followed by TNF-i in 46 (41.8%), rituximab in 20 (18.2%), JAK-i in 12 (10.9%), and IL6-i in 7 (6.4%) patients. The mean (SD) anti-SARS-CoV-2 S antibody titer of only the rituximab subgroup significantly differed from the controls (P = 0.012). Conclusion The most prevalent ARD immunomodulators (Cs-DMARDs, TNF-i, JAK-i, and IL6-i) were associated with comparable seroconversion rates to the BNT162b2 vaccine. In comparison, rituximab was significantly associated with decreased immunogenicity.
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Rider LG, Parks CG, Wilkerson J, Schiffenbauer AI, Kwok RK, Noroozi Farhadi P, Nazir S, Ritter R, Sirotich E, Kennedy K, Larche MJ, Levine M, Sattui SE, Liew JW, Harrison CO, Moni TT, Miller AK, Putman M, Hausmann J, Simard JF, Sparks JA, Miller FW. Baseline Factors Associated with Self-reported Disease Flares Following COVID-19 Vaccination among Adults with Systemic Rheumatic Disease: Results from the COVID-19 Global Rheumatology Alliance Vaccine Survey. Rheumatology (Oxford) 2022; 61:SI143-SI150. [PMID: 35460240 DOI: 10.1093/rheumatology/keac249] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/30/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To examine the frequency of, and risk factors for, disease flare following COVID-19 vaccination in patients with systemic rheumatic disease (SRD). METHODS An international study was conducted from April 2 to August 16, 2021, using an online survey of 5619 adults with SRD for adverse events following COVID-19 vaccination, including flares of disease requiring a change in treatment. We examined risk factors identified a priori based on published associations with SRD activity and SARS-CoV-2 severity, including demographics, SRD type, comorbidities, vaccine type, cessation of immunosuppressive medications around vaccination, and history of reactions to non-COVID-19 vaccines, using multivariable logistic regression. RESULTS Flares requiring a change in treatment following COVID-19 vaccination were reported by 4.9% of patients. Compared with rheumatoid arthritis, certain SRD, including systemic lupus erythematosus (OR 1.51, 95%CI 1.03, 2.20), psoriatic arthritis (OR 1.95, 95%CI 1.20, 3.18), and polymyalgia rheumatica (OR 1.94, 95%CI 1.08, 2.48) were associated with higher odds of flare, while idiopathic inflammatory myopathies were associated with lower odds for flare (OR 0.54, 95%CI 0.31-0.96). The Oxford-AstraZeneca vaccine was associated with higher odds of flare relative to the Pfizer-BioNTech vaccine (OR 1.44, 95%CI 1.07, 1.95), as were a prior reaction to a non-COVID-19 vaccine (OR 2.50, 95%CI 1.76, 3.54) and female sex (OR 2.71, 95%CI 1.55, 4.72). CONCLUSION SRD flares requiring changes in treatment following COVID-19 vaccination were uncommon in this large international study. Several potential risk factors, as well as differences by disease type, warrant further examination in prospective cohorts.
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Affiliation(s)
- Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
| | | | | | - Adam I Schiffenbauer
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
| | - Richard K Kwok
- Office of the Director, NIEHS, NIH, Research Triangle Park, NC, USA
| | - Payam Noroozi Farhadi
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
| | - Sarvar Nazir
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
| | | | | | - Kevin Kennedy
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | | | - Mitchell Levine
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Sebastian E Sattui
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean W Liew
- Section of Rheumatology, Boston University School of Medicine, Boston, MA, USA
| | | | - Tarin T Moni
- Department of Biochemistry and Biomedical Sciences, McMaster University Faculty of Science, Hamilton, ON, Canada
| | - Aubrey K Miller
- Office of the Director, NIEHS, NIH, Research Triangle Park, NC, USA
| | | | - Jonathan Hausmann
- Program in Rheumatology, Boston Children's Hospital, Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
| | - Julia F Simard
- Department of Epidemiology and Population Health, and Immunology and Rheumatology (Department of Medicine), Stanford University School of Medicine, USA
| | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Frederick W Miller
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences (NIEHS, National Institutes of Health (NIH), Bethesda, MD, USA)
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Pasoto SG, Halpern ASR, Guedes LKN, Ribeiro ACM, Yuki ENF, Saad CGS, da Silva CAA, de Vinci Kanda Kupa L, Villamarín LEB, de Oliveira Martins VA, Martins CCMF, Deveza GBH, Leon EP, Bueno C, Pedrosa TN, Santos REB, Soares R, Aikawa NE, Bonfa E. Inactivated SARS-CoV-2 vaccine in primary Sjögren’s syndrome: humoral response, safety, and effects on disease activity. Clin Rheumatol 2022; 41:2079-2089. [PMID: 35306594 PMCID: PMC8934123 DOI: 10.1007/s10067-022-06134-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 12/02/2022]
Abstract
Introduction There is no study specifically focused on SARS-CoV-2 vaccine in primary Sjögren’s syndrome (pSS). Objectives To assess the immunogenicity, safety, possible effects on disease activity, and autoantibody profile of the Sinovac-CoronaVac vaccine in pSS. Methods Fifty-one pSS patients and 102 sex- and age-balanced controls without autoimmune diseases were included in a prospective phase 4 trial of the Sinovac-CoronaVac vaccine (two doses 28 days apart, D0/D28). Participants were assessed in three face-to-face visits (D0/D28 and six weeks after the 2nd dose (D69)) regarding adverse effects; clinical EULAR Sjögren’s Syndrome Disease Activity Index (clinESSDAI); anti-SARS-CoV-2 S1/S2 IgG (seroconversion (SC) and geometric mean titers (GMT)); neutralizing antibodies (NAb); and pSS autoantibody profile. Results Patients and controls had comparable female sex frequency (98.0% vs. 98.0%, p = 1.000) and mean age (53.5 ± 11.7 vs. 53.4 ± 11.4 years, p = 0.924), respectively. On D69, pSS patients presented moderate SC (67.5% vs. 93.0%, p < 0.001) and GMT (22.5 (95% CI 14.6–34.5) vs. 59.6 (95% CI 51.1–69.4) AU/mL, p < 0.001) of anti-SARS-CoV-2 S1/S2 IgG but lower than controls, and also, moderate NAb frequency (52.5% vs. 73.3%, p = 0.021) but lower than controls. Median neutralizing activity on D69 was comparable in pSS (58.6% (IQR 43.7–63.6)) and controls (64% (IQR 46.4–81.1)) (p = 0.219). Adverse events were mild. clinESSDAI and anti-Ro(SS-A)/anti-La(SS-B) levels were stable throughout the study (p > 0.05). Conclusion Sinovac-CoronaVac vaccine is safe in pSS, without a deleterious impact on disease activity, and has a moderate short-term humoral response, though lower than controls. Thus, a booster dose needs to be studied in these patients. Trial registration ClinicalTrials.gov Identifier: NCT04754698.Key Points • Sinovac-CoronaVac vaccine is safe in pSS, without a detrimental effect on systemic disease activity, and has a moderate short-term humoral response • A booster doseshould be considered in these patients |
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Affiliation(s)
- Sandra Gofinet Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil.
| | - Ari Stiel Radu Halpern
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Lissiane Karine Noronha Guedes
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Ana Cristina Medeiros Ribeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Emily Neves Figueiredo Yuki
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Carla Gonçalves Schahin Saad
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Clovis Artur Almeida da Silva
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Léonard de Vinci Kanda Kupa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Lorena Elizabeth Betancourt Villamarín
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Victor Adriano de Oliveira Martins
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Carolina Campagnoli Machado Freire Martins
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Giordano Bruno Henriques Deveza
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Elaine Pires Leon
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Cleonice Bueno
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Tatiana Nascimento Pedrosa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Roseli Eliana Beseggio Santos
- Central Laboratory Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Renata Soares
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Nádia Emi Aikawa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3º andar, sala 3190, Sao Paulo, SP, 01246-903, Brazil
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Lin S, Kennedy NA, Saifuddin A, Sandoval DM, Reynolds CJ, Seoane RC, Kottoor SH, Pieper FP, Lin KM, Butler DK, Chanchlani N, Nice R, Chee D, Bewshea C, Janjua M, McDonald TJ, Sebastian S, Alexander JL, Constable L, Lee JC, Murray CD, Hart AL, Irving PM, Jones GR, Kok KB, Lamb CA, Lees CW, Altmann DM, Boyton RJ, Goodhand JR, Powell N, Ahmad T. Antibody decay, T cell immunity and breakthrough infections following two SARS-CoV-2 vaccine doses in inflammatory bowel disease patients treated with infliximab and vedolizumab. Nat Commun 2022; 13:1379. [PMID: 35296643 PMCID: PMC8927425 DOI: 10.1038/s41467-022-28517-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/26/2022] [Indexed: 12/15/2022] Open
Abstract
Anti tumour necrosis factor (anti-TNF) drugs increase the risk of serious respiratory infection and impair protective immunity following pneumococcal and influenza vaccination. Here we report SARS-CoV-2 vaccine-induced immune responses and breakthrough infections in patients with inflammatory bowel disease, who are treated either with the anti-TNF antibody, infliximab, or with vedolizumab targeting a gut-specific anti-integrin that does not impair systemic immunity. Geometric mean [SD] anti-S RBD antibody concentrations are lower and half-lives shorter in patients treated with infliximab than vedolizumab, following two doses of BNT162b2 (566.7 U/mL [6.2] vs 4555.3 U/mL [5.4], p <0.0001; 26.8 days [95% CI 26.2 - 27.5] vs 47.6 days [45.5 - 49.8], p <0.0001); similar results are also observed with ChAdOx1 nCoV-19 vaccination (184.7 U/mL [5.0] vs 784.0 U/mL [3.5], p <0.0001; 35.9 days [34.9 - 36.8] vs 58.0 days [55.0 - 61.3], p value < 0.0001). One fifth of patients fail to mount a T cell response in both treatment groups. Breakthrough SARS-CoV-2 infections are more frequent (5.8% (201/3441) vs 3.9% (66/1682), p = 0.0039) in patients treated with infliximab than vedolizumab, and the risk of breakthrough SARS-CoV-2 infection is predicted by peak anti-S RBD antibody concentration after two vaccine doses. Irrespective of the treatments, higher, more sustained antibody levels are observed in patients with a history of SARS-CoV-2 infection prior to vaccination. Our results thus suggest that adapted vaccination schedules may be required to induce immunity in at-risk, anti-TNF-treated patients.
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Affiliation(s)
- Simeng Lin
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Aamir Saifuddin
- Department of Gastroenterology, St Marks Hospital and Academic Institute, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | | | | | - Rocio Castro Seoane
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Sherine H Kottoor
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | | | - Kai-Min Lin
- Department of Infectious Disease, Imperial College London, London, UK
| | - David K Butler
- Department of Infectious Disease, Imperial College London, London, UK
| | - Neil Chanchlani
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
- Department of Biochemistry, Exeter Clinical Laboratory International, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Desmond Chee
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Claire Bewshea
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Malik Janjua
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Timothy J McDonald
- Department of Biochemistry, Exeter Clinical Laboratory International, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Shaji Sebastian
- IBD Unit, Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - James L Alexander
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Laura Constable
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - James C Lee
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
- Genetic Mechanisms of Disease Laboratory, The Francis Crick Institute, London, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Charles D Murray
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | - Ailsa L Hart
- Department of Gastroenterology, St Marks Hospital and Academic Institute, London, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Gareth-Rhys Jones
- Department of Gastroenterology, Western General Hospital, NHS Lothian, Edinburgh, UK
- Centre for Inflammation Research, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Klaartje B Kok
- Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Christopher A Lamb
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Charlie W Lees
- Department of Gastroenterology, Western General Hospital, NHS Lothian, Edinburgh, UK
- Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Daniel M Altmann
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, London, UK
- Lung Division, Royal Brompton Hospital and Harefield Hospitals, London, UK
| | - James R Goodhand
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Nick Powell
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK.
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Chanchlani N, Lin S, Chee D, Hamilton B, Nice R, Arkir Z, Bewshea C, Cipriano B, Derikx LAAP, Dunlop A, Greathead L, Griffiths RL, Ibraheim H, Kelleher P, Kok KB, Lees CW, MacDonald J, Sebastian S, Smith PJ, McDonald TJ, Irving PM, Powell N, Kennedy NA, Goodhand JR, Ahmad T. Adalimumab and Infliximab Impair SARS-CoV-2 Antibody Responses: Results from a Therapeutic Drug Monitoring Study in 11 422 Biologic-Treated Patients. J Crohns Colitis 2022; 16:389-397. [PMID: 34473254 PMCID: PMC8499950 DOI: 10.1093/ecco-jcc/jjab153] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Infliximab attenuates serological responses to SARS-CoV-2 infection. Whether this is a class effect, or if anti-tumour necrosis factor [anti-TNF] level influences serological responses, remains unknown. METHODS Seroprevalence and the magnitude of SARS-CoV-2 nucleocapsid antibody responses were measured in surplus serum from 11 422 (53.3% [6084] male; median age 36.8 years) patients with immune-mediated inflammatory diseases, stored at six therapeutic drug monitoring laboratories between January 29 and September 30, 2020. Data were linked to nationally held SARS-CoV-2 PCR results to July 11, 2021. RESULTS Rates of PCR-confirmed SARS-CoV-2 infection were similar across treatment groups. Seroprevalence rates were lower in infliximab- and adalimumab- than vedolizumab-treated patients (infliximab: 3.0% [178/5893], adalimumab: 3.0% [152/5074], vedolizumab: 6.7% [25/375], p = 0.003). The magnitude of SARS-CoV-2 reactivity was similar in infliximab- vs adalimumab-treated patients (median 4.30 cut-off index [COI] [1.94-9.96] vs 5.02 [2.18-18.70], p = 0.164), but higher in vedolizumab-treated patients (median 21.60 COI [4.39-68.10, p < 0.004). Compared to patients with detectable infliximab and adalimumab drug levels, patients with undetectable drug levels [<0.8 mg/L] were more likely to be seropositive for SARS-CoV-2 antibodies. One-third of patients who had PCR testing prior to antibody testing failed to seroconvert, all were treated with anti-TNF. Subsequent positive PCR-confirmed SARS-CoV-2 was seen in 7.9% [12/152] of patients after a median time of 183.5 days [129.8-235.3], without differences between drugs. CONCLUSION Anti-TNF treatment is associated with lower SARS-CoV-2 nucleocapsid seroprevalence and antibody reactivity when compared to vedolizumab-treated patients. Higher seropositivity rates in patients with undetectable anti-TNF levels support a causal relationship, although confounding factors, such as combination therapy with a immunomodulator, may have influenced the results.
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Affiliation(s)
- Neil Chanchlani
- Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Simeng Lin
- Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Desmond Chee
- Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Benjamin Hamilton
- Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Biochemistry, Exeter Clinical Laboratory International, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Zehra Arkir
- Viapath Analytics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Claire Bewshea
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Bessie Cipriano
- Gastroenterology, Barts and The London NHS Trust, London, UK
| | - Lauranne A A P Derikx
- Gastroenterology, Western General Hospital, NHS Lothian, Edinburgh, UK
- Gastroenterology and Hepatology, Inflammatory Bowel Disease Center, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Allan Dunlop
- Biochemistry, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Louise Greathead
- Infection & Immunity Sciences, North West London Pathology, London, UK
| | | | - Hajir Ibraheim
- Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Peter Kelleher
- Infection & Immunity Sciences, North West London Pathology, London, UK
- Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - Klaartje B Kok
- Gastroenterology, Barts and The London NHS Trust, London, UK
- Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry Blizard Institute, London, UK
| | - Charlie W Lees
- Gastroenterology, Western General Hospital, NHS Lothian, Edinburgh, UK
- Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Jonathan MacDonald
- Gastroenterology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Shaji Sebastian
- IBD Unit – Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - Philip J Smith
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Timothy J McDonald
- Biochemistry, Exeter Clinical Laboratory International, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Peter M Irving
- Gastroenterology, Guy’s and St Thomas’ Hospitals NHS Trust, London, UK
- School of Immunology & Microbial Sciences, King’s College London, London, UK
| | - Nick Powell
- Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Nicholas A Kennedy
- Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - James R Goodhand
- Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Tariq Ahmad
- Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
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Araujo CSR, Medeiros-Ribeiro AC, Saad CGS, Bonfiglioli KR, Domiciano DS, Shimabuco AY, Silva MSR, Yuki EFN, Pasoto SG, Pedrosa T, Kupa LDVK, Zou G, Pereira RMR, Silva CA, Aikawa NE, Bonfa E. Two-week methotrexate discontinuation in patients with rheumatoid arthritis vaccinated with inactivated SARS-CoV-2 vaccine: a randomised clinical trial. Ann Rheum Dis 2022; 81:889-897. [PMID: 35193873 DOI: 10.1136/annrheumdis-2021-221916] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/07/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the effect on immunogenicity and safety of 2-week methotrexate (MTX) discontinuation after each dose of the Sinovac-CoronaVac vaccine versus MTX maintenance in patients with rheumatoid arthritis (RA). METHODS This was a single-centre, prospective, randomised, investigator-blinded, intervention study (NCT04754698, CoronavRheum) including adult patients with RA (stable Clinical Disease Activity Index (CDAI) ≤10, prednisone ≤7.5 mg/day) randomised (1:1) to withdraw MTX (MTX-hold) for 2 weeks after each vaccine dose or maintain MTX (MTX-maintain), evaluated at day 0 (D0), D28 and D69. Coprimary outcomes were anti-SARS-CoV-2 S1/S2 IgG seroconversion (SC) and neutralising antibody (NAb) positivity at D69. Secondary outcomes were geometric mean titres (GMT) and flare rates. For immunogenicity analyses, we excluded patients with baseline positive IgG/NAb, and for safety reasons those who flared at D28 (CDAI >10) and did not withdraw MTX twice. RESULTS Randomisation included 138 patients with 9 exclusions (5 COVID-19, 4 protocol violations). Safety evaluation included 60 patients in the MTX-hold and 69 patients in the MTX-maintain group. Further exclusions included 27 patients (13 (21.7%) vs 14 (20.3%), p=0.848) with positive baseline IgG/NAb and 10 patients (21.3%) in MTX-hold with CDAI >10 at D28. At D69, the MTX-hold group (n=37) had a higher rate of SC than the MTX-maintain group (n=55) (29 (78.4%) vs 30 (54.5%), p=0.019), with parallel augmentation in GMT (34.2 (25.2-46.4) vs 16.8 (11.9-23.6), p=0.006). No differences were observed for NAb positivity (23 (62.2%) vs 27 (49.1%), p=0.217). At D28 flare, the rates were comparable in both groups (CDAI, p=0.122; Disease Activity Score in 28 joints with C reactive protein, p=0.576), whereas CDAI >10 was more frequent in MTX-hold at D69 (p=0.024). CONCLUSION We provided novel data that 2-week MTX withdrawal after each dose of the Sinovac-CoronaVac vaccine improves anti-SARS-CoV-2 IgG response. The increased flare rates after the second MTX withdrawal may be attributed to the short-term interval between vaccine doses. This strategy requires close surveillance and shared decision making due to the possibility of flares.
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Affiliation(s)
| | | | - Carla G S Saad
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Karina Rossi Bonfiglioli
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Diogo Souza Domiciano
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Andrea Yukie Shimabuco
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | | | | | - Sandra Gofinet Pasoto
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Tatiana Pedrosa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | | | - Gioanna Zou
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Rosa M R Pereira
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Clóvis Artur Silva
- Pediatric Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Nádia Emi Aikawa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Sao Paulo, Brazil
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Cellular and humoral Immune response to mRNA COVID-19 vaccination in subjects with chronic lymphocytic leukemia. Blood Adv 2021; 6:1207-1211. [PMID: 34872103 PMCID: PMC8651482 DOI: 10.1182/bloodadvances.2021006633] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/02/2021] [Indexed: 11/20/2022] Open
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Tang W, Gartshteyn Y, Ricker E, Inzerillo S, Murray S, Khalili L, Askanase A. The Use of COVID-19 Vaccines in Patients with SLE. Curr Rheumatol Rep 2021; 23:79. [PMID: 34767100 PMCID: PMC8586600 DOI: 10.1007/s11926-021-01046-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 02/06/2023]
Abstract
Purpose of Review Three COVID-19 vaccines obtained emergency authorization from the Food and Drug Administration (FDA) and are widely used in the USA. Unfortunately, there is a paucity of evidence on the safety and efficacy of these vaccines in patients with autoimmune inflammatory rheumatic diseases (AIIRD), as these patients were excluded from all phases of vaccine development. Here we reviewed current data on COVID-19 vaccination in patients with AIIRD, with emphasis on systemic lupus erythematosus (SLE), and provided a comprehensive update on the benefits and risks of vaccination. Recent Findings Patients with SLE have worse immune responses following SARS-CoV-2 vaccination than healthy controls. The efficacy of the COVID-19 vaccines seems to be further reduced by immunosuppressive medications, such as glucocorticoids (GC), methotrexate (MTX), mycophenolate/mycophenolic acid (MMF), and rituximab (RTX). However, these data do not substantiate that AIIRD patients are at greater risk of disease flares or have a higher incidence of side effects following vaccination. There is no significant safety concern for the use of COVID-19 vaccines in patients with AIIRD. Summary The benefits of vaccination far outweigh the risks in patients with AIIRD, including SLE. More data are needed to determine the necessity of a booster vaccine dose and appropriate adjustment of immunosuppressants around the administration of vaccine.
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Affiliation(s)
- Wei Tang
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, 630 West 168th Street, P&S 10-508, New York, NY, 10032, USA
| | - Yevgeniya Gartshteyn
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, 630 West 168th Street, P&S 10-508, New York, NY, 10032, USA
| | - Edd Ricker
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Sean Inzerillo
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, 630 West 168th Street, P&S 10-508, New York, NY, 10032, USA
| | - Shane Murray
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, 630 West 168th Street, P&S 10-508, New York, NY, 10032, USA
| | - Leila Khalili
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, 630 West 168th Street, P&S 10-508, New York, NY, 10032, USA
| | - Anca Askanase
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, 630 West 168th Street, P&S 10-508, New York, NY, 10032, USA.
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Picchianti Diamanti A, Rosado MM, Nicastri E, Sesti G, Pioli C, Laganà B. Severe Acute Respiratory Syndrome Coronavirus-2 Infection and Autoimmunity 1 Year Later: The Era of Vaccines. Front Immunol 2021; 12:708848. [PMID: 34659200 PMCID: PMC8515900 DOI: 10.3389/fimmu.2021.708848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/27/2021] [Indexed: 12/15/2022] Open
Abstract
Impressive efforts have been made by researchers worldwide in the development of target vaccines against the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and in improving the management of immunomodulating agents. Currently, different vaccine formulations, such as viral vector, mRNA, and protein-based, almost all directed toward the spike protein that includes the domain for receptor binding, have been approved. Although data are not conclusive, patients affected by autoimmune rheumatic diseases (ARDs) seem to have a slightly higher disease prevalence, risk of hospitalization, and death from coronavirus disease-2019 (COVID-19) than the general population. Therefore, ARD patients, under immunosuppressive agents, have been included among the priority target groups for vaccine administration. However, specific cautions are needed to optimize vaccine safety and effectiveness in these patients, such as modification in some of the ongoing immunosuppressive therapies and the preferential use of mRNA other than vector-based vaccines. Immunomodulating agents can be a therapeutic opportunity for the management of COVID-19 patients; however, their clinical impact depends on how they are handled. To place in therapy immunomodulating agents in the correct window of opportunity throughout the identification of surrogate markers of disease progression and host immune response is mandatory to optimize patient's outcome.
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Affiliation(s)
- Andrea Picchianti Diamanti
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Emanuele Nicastri
- Clinical Division of Infectious Diseases, Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Rome, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Claudio Pioli
- Laboratory of Biomedical Technologies, Division of Health Protection Technologies, Italian National Agency for New Technologies, Energy and Sustainable Economic Development, Rome, Italy
| | - Bruno Laganà
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
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Moyon Q, Sterlin D, Miyara M, Anna F, Mathian A, Lhote R, Ghillani-Dalbin P, Breillat P, Mudumba S, de Alba S, Cohen-Aubart F, Haroche J, Pha M, Boutin THD, Chaieb H, Flores PM, Charneau P, Gorochov G, Amoura Z. BNT162b2 vaccine-induced humoral and cellular responses against SARS-CoV-2 variants in systemic lupus erythematosus. Ann Rheum Dis 2021; 81:575-583. [PMID: 34607791 PMCID: PMC8494536 DOI: 10.1136/annrheumdis-2021-221097] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/12/2021] [Indexed: 01/11/2023]
Abstract
Objectives Our aim was to evaluate systemic lupus erythematosus (SLE) disease activity and SARS-CoV-2-specific immune responses after BNT162b2 vaccination. Methods In this prospective study, disease activity and clinical assessments were recorded from the first dose of vaccine until day 15 after the second dose in 126 patients with SLE. SARS-CoV-2 antibody responses were measured against wild-type spike antigen, while serum-neutralising activity was assessed against the SARS-CoV-2 historical strain and variants of concerns (VOCs). Vaccine-specific T cell responses were quantified by interferon-γ release assay after the second dose. Results BNT162b2 was well tolerated and no statistically significant variations of BILAG (British Isles Lupus Assessment Group) and SLEDAI (SLE Disease Activity Index) scores were observed throughout the study in patients with SLE with active and inactive disease at baseline. Mycophenolate mofetil (MMF) and methotrexate (MTX) treatments were associated with drastically reduced BNT162b2 antibody response (β=−78, p=0.007; β=−122, p<0.001, respectively). Anti-spike antibody response was positively associated with baseline total immunoglobulin G serum levels, naïve B cell frequencies (β=2, p=0.018; β=2.5, p=0.003) and SARS-CoV-2-specific T cell response (r=0.462, p=0.003). In responders, serum neutralisation activity decreased against VOCs bearing the E484K mutation but remained detectable in a majority of patients. Conclusion MMF, MTX and poor baseline humoral immune status, particularly low naïve B cell frequencies, are independently associated with impaired BNT162b2 mRNA antibody response, delineating patients with SLE who might need adapted vaccine regimens and follow-up.
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Affiliation(s)
- Quentin Moyon
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
| | - Delphine Sterlin
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France.,Assistance Publique Hôpitaux de Paris (AP-HP), Département d'Immunologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Makoto Miyara
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France.,Assistance Publique Hôpitaux de Paris (AP-HP), Département d'Immunologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - François Anna
- Virology Department, Institut Pasteur-TheraVectys Joint Lab, Paris, France.,Unité de Virologie Moléculaire et Vaccinologie, Institut Pasteur, Paris, France
| | - Alexis Mathian
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
| | - Raphael Lhote
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
| | - Pascale Ghillani-Dalbin
- Assistance Publique Hôpitaux de Paris (AP-HP), Département d'Immunologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Paul Breillat
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France
| | - Sasi Mudumba
- Assay Development Department, Genalyte Inc, San Diego, California, USA
| | - Sophia de Alba
- Assay Development Department, Genalyte Inc, San Diego, California, USA
| | - Fleur Cohen-Aubart
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
| | - Julien Haroche
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
| | - Micheline Pha
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
| | - Thi Huong Du Boutin
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
| | - Hedi Chaieb
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
| | - Pedro Macedo Flores
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France.,Mathématiques appliquées, Sorbonne Universite Faculte des Sciences et Ingenierie, Paris, France
| | - Pierre Charneau
- Virology Department, Institut Pasteur-TheraVectys Joint Lab, Paris, France.,Unité de Virologie Moléculaire et Vaccinologie, Institut Pasteur, Paris, France
| | - Guy Gorochov
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France .,Assistance Publique Hôpitaux de Paris (AP-HP), Département d'Immunologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Zahir Amoura
- Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France .,Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière (GHPS), French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Paris, France
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Furer V, Eviatar T, Zisman D, Peleg H, Paran D, Levartovsky D, Zisapel M, Elalouf O, Kaufman I, Meidan R, Broyde A, Polachek A, Wollman J, Litinsky I, Meridor K, Nochomovitz H, Silberman A, Rosenberg D, Feld J, Haddad A, Gazzit T, Elias M, Higazi N, Kharouf F, Shefer G, Sharon O, Pel S, Nevo S, Elkayam O. Immunogenicity and safety of the BNT162b2 mRNA COVID-19 vaccine in adult patients with autoimmune inflammatory rheumatic diseases and in the general population: a multicentre study. Ann Rheum Dis 2021; 80:1330-1338. [PMID: 34127481 PMCID: PMC8206170 DOI: 10.1136/annrheumdis-2021-220647] [Citation(s) in RCA: 450] [Impact Index Per Article: 150.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/27/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Vaccination represents a cornerstone in mastering the COVID-19 pandemic. Data on immunogenicity and safety of messenger RNA (mRNA) vaccines in patients with autoimmune inflammatory rheumatic diseases (AIIRD) are limited. METHODS A multicentre observational study evaluated the immunogenicity and safety of the two-dose regimen BNT162b2 mRNA vaccine in adult patients with AIIRD (n=686) compared with the general population (n=121). Serum IgG antibody levels against SARS-CoV-2 spike S1/S2 proteins were measured 2-6 weeks after the second vaccine dose. Seropositivity was defined as IgG ≥15 binding antibody units (BAU)/mL. Vaccination efficacy, safety, and disease activity were assessed within 6 weeks after the second vaccine dose. RESULTS Following vaccination, the seropositivity rate and S1/S2 IgG levels were significantly lower among patients with AIIRD versus controls (86% (n=590) vs 100%, p<0.0001 and 132.9±91.7 vs 218.6±82.06 BAU/mL, p<0.0001, respectively). Risk factors for reduced immunogenicity included older age and treatment with glucocorticoids, rituximab, mycophenolate mofetil (MMF), and abatacept. Rituximab was the main cause of a seronegative response (39% seropositivity). There were no postvaccination symptomatic cases of COVID-19 among patients with AIIRD and one mild case in the control group. Major adverse events in patients with AIIRD included death (n=2) several weeks after the second vaccine dose, non-disseminated herpes zoster (n=6), uveitis (n=2), and pericarditis (n=1). Postvaccination disease activity remained stable in the majority of patients. CONCLUSION mRNA BNTb262 vaccine was immunogenic in the majority of patients with AIIRD, with an acceptable safety profile. Treatment with glucocorticoids, rituximab, MMF, and abatacept was associated with a significantly reduced BNT162b2-induced immunogenicity.
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Affiliation(s)
- Victoria Furer
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Tali Eviatar
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Devy Zisman
- Rheumatology Unit, Carmel Hospital, Haifa, Israel
- Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Hagit Peleg
- Rheumatology Unit, Hadassah University Hospital, Jerusalem, Israel
| | - Daphna Paran
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - David Levartovsky
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Michael Zisapel
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ofir Elalouf
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Ilana Kaufman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Roni Meidan
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
- Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Adi Broyde
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Ari Polachek
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Jonathan Wollman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Ira Litinsky
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Katya Meridor
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Hila Nochomovitz
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Adi Silberman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Dana Rosenberg
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Joy Feld
- Rheumatology Unit, Carmel Hospital, Haifa, Israel
| | - Amir Haddad
- Rheumatology Unit, Carmel Hospital, Haifa, Israel
| | - Tal Gazzit
- Rheumatology Unit, Carmel Hospital, Haifa, Israel
| | - Muna Elias
- Rheumatology Unit, Carmel Hospital, Haifa, Israel
| | - Nizar Higazi
- Rheumatology Unit, Carmel Hospital, Haifa, Israel
| | - Fadi Kharouf
- Rheumatology Unit, Hadassah University Hospital, Jerusalem, Israel
- The Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Jerusalem, Israel
| | - Gabi Shefer
- Endocrinology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Orly Sharon
- Endocrinology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sara Pel
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sharon Nevo
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ori Elkayam
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
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50
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Haberman RH, Herati R, Simon D, Samanovic M, Blank RB, Tuen M, Koralov SB, Atreya R, Tascilar K, Allen JR, Castillo R, Cornelius AR, Rackoff P, Solomon G, Adhikari S, Azar N, Rosenthal P, Izmirly P, Samuels J, Golden B, Reddy SM, Neurath MF, Abramson SB, Schett G, Mulligan MJ, Scher JU. Methotrexate hampers immunogenicity to BNT162b2 mRNA COVID-19 vaccine in immune-mediated inflammatory disease. Ann Rheum Dis 2021; 80:1339-1344. [PMID: 34035003 PMCID: PMC8219484 DOI: 10.1136/annrheumdis-2021-220597] [Citation(s) in RCA: 168] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/10/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the humoral and cellular immune response to messenger RNA (mRNA) COVID-19 vaccines in patients with immune-mediated inflammatory diseases (IMIDs) on immunomodulatory treatment. METHODS Established patients at New York University Langone Health with IMID (n=51) receiving the BNT162b2 mRNA vaccination were assessed at baseline and after second immunisation. Healthy subjects served as controls (n=26). IgG antibody responses to the spike protein were analysed for humoral response. Cellular immune response to SARS-CoV-2 was further analysed using high-parameter spectral flow cytometry. A second independent, validation cohort of controls (n=182) and patients with IMID (n=31) from Erlangen, Germany, were also analysed for humoral immune response. RESULTS Although healthy subjects (n=208) and patients with IMID on biologic treatments (mostly on tumour necrosis factor blockers, n=37) demonstrate robust antibody responses (over 90%), those patients with IMID on background methotrexate (n=45) achieve an adequate response in only 62.2% of cases. Similarly, patients with IMID on methotrexate do not demonstrate an increase in CD8+ T-cell activation after vaccination. CONCLUSIONS In two independent cohorts of patients with IMID, methotrexate, a widely used immunomodulator for the treatment of several IMIDs, adversely affected humoral and cellular immune response to COVID-19 mRNA vaccines. Although precise cut-offs for immunogenicity that correlate with vaccine efficacy are yet to be established, our findings suggest that different strategies may need to be explored in patients with IMID taking methotrexate to increase the chances of immunisation efficacy against SARS-CoV-2 as has been demonstrated for augmenting immunogenicity to other viral vaccines.
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Affiliation(s)
- Rebecca H Haberman
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- NYU Langone Psoriatic Arthritis Center, New York University School of Medicine, New York, New York, USA
| | - Ramin Herati
- Divison of Infectious Disease and Immunology and NYU Langone Vaccine Center, Department of Medicine, New York University School of Medicine, New York, NY, USA
- New York University Grossman School of Medicine, New York, New York, USA
| | - David Simon
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Marie Samanovic
- Divison of Infectious Disease and Immunology and NYU Langone Vaccine Center, Department of Medicine, New York University School of Medicine, New York, NY, USA
- New York University Grossman School of Medicine, New York, New York, USA
| | - Rebecca B Blank
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- New York University Grossman School of Medicine, New York, New York, USA
| | - Michael Tuen
- Divison of Infectious Disease and Immunology and NYU Langone Vaccine Center, Department of Medicine, New York University School of Medicine, New York, NY, USA
- New York University Grossman School of Medicine, New York, New York, USA
| | - Sergei B Koralov
- Department of Pathology, New York University Grossman School of Medicine, New York, New York, USA
| | - Raja Atreya
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Department of Internal Medicine 1, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Koray Tascilar
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Joseph R Allen
- Divison of Infectious Disease and Immunology and NYU Langone Vaccine Center, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Rochelle Castillo
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- NYU Langone Psoriatic Arthritis Center, New York University School of Medicine, New York, New York, USA
| | - Amber R Cornelius
- Divison of Infectious Disease and Immunology and NYU Langone Vaccine Center, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Paula Rackoff
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Gary Solomon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Samrachana Adhikari
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Natalie Azar
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Pamela Rosenthal
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Peter Izmirly
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Jonathan Samuels
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Brian Golden
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Soumya M Reddy
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- NYU Langone Psoriatic Arthritis Center, New York University School of Medicine, New York, New York, USA
| | - Markus F Neurath
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Steven B Abramson
- New York University Grossman School of Medicine, New York, New York, USA
- Rheumatology Research, NYU-NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Georg Schett
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Mark J Mulligan
- Divison of Infectious Disease and Immunology and NYU Langone Vaccine Center, Department of Medicine, New York University School of Medicine, New York, NY, USA
- New York University Grossman School of Medicine, New York, New York, USA
| | - Jose U Scher
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- NYU Langone Psoriatic Arthritis Center, New York University School of Medicine, New York, New York, USA
- New York University Grossman School of Medicine, New York, New York, USA
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