Vaccine Response in Patients With Multiple Sclerosis Receiving Teriflunomide

De-escalation and Discontinuation of Disease-Modifying Therapies in Multiple Sclerosis

PURPOSE OF REVIEW

Long-term use of multiple sclerosis (MS) disease-modifying therapies (DMTs) is standard practice to prevent accumulation of disability. Immunosenescence and other age-related changes lead to an altered risk-benefit ratio for older patients on DMTs. This article reviews recent research on the topic of de-escalation and discontinuation of MS DMTs.

RECENT FINDINGS

Observational and interventional studies have shed light on what happens to patients who de-escalate or discontinue DMTs and the factors, such as age, treatment type, and presence of recent disease activity, that influence outcomes. Though many questions remain, recent findings have been valuable for the development of an evidence-based approach to making de-escalation and discontinuation decisions in MS.

Humoral immune response and safety of Sars-Cov-2 vaccine in people with multiple sclerosis

BACKGROUND

For the past three years, the pandemic has had a major effect on global public health, mainly on those with underlying medical conditions, such as people living with Multiple Sclerosis. Vaccination among this group is of great importance, and the long-term impacts of vaccination and its safety on the health of these patients will continue to be revealed. Therefore, risks related to vaccination and immune response need to be assessed. The objective here was to characterize the immune response, short-term safety, and the effects of multiple variables on these factors after COVID-19 vaccination (mainly Sinopharm) among people with Multiple Sclerosis. We assessed the short-term safety and humoral SARS-COV-2 anti-RBD IgG response using a data collection form and Immunoassay, respectively.

RESULTS

No severe adverse events or MS relapse was observed. Myalgia/body pain (26.7%), low-grade fever (22.2%), and mild headache (15.6%) were the most common adverse events. The use and type of vaccine influenced the frequency of side effects with a p-value < 0.0001. Regarding immune response, patients on rituximab and fingolimod had a lower antibody titer compared to other medications. With a significant difference, hybrid immunity (p-value: 0.047) and type of DMTs (p-value: 0.017) affected the humoral response.

CONCLUSION

There is a low incidence of serious adverse effects, MS worsening or relapse after COVID-19 vaccination, and mainly, side effects are similar to that of the general population. It appears that treatment with various disease-modifying therapies does not induce or worsen the post-vaccination side effects, although some, including Rituximab and fingolimod, may affect the immunity induced after vaccination.

Comparing the consequences of COVID-19 vaccination between central nervous system (CNS) demyelinating diseases and other neurological disorders

BACKGROUND

Vaccination constitutes a crucial preventive measure against COVID-19 infection. Concerns have been raised regarding the efficacy of vaccines in multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) patients due to various immunomodulatory medications and potential adverse events that may impact neurological function. This study aimed to explore the implications of COVID-19 vaccination within MS and NMSOD patients and compare it with other neurological disorders (OND).

METHOD

In this cross-sectional study conducted in Isfahan, Iran, baseline data and information on COVID-19 infections and vaccinations were collected from MS, NMOSD, and OND patients between September 2021 and September 2022. The predominant neurological disorders identified among OND patients encompassed headache, epilepsy, and Parkinson's disease. Logistic regression analysis was employed to compare COVID-19 vaccination outcomes among different patient groups, presenting odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

The study included 1,307 participants, with 738 having MS, 96 having NMOSD, 76 having clinically isolated syndrome (CIS), and 397 having OND. Significantly higher odds of post-vaccination COVID-19 infection were detected in MS (OR = 3.86, p < 0.001) NMOSD (OR = 2.77, p = 0.015) patients than OND patients. The prior history of COVID-19 infection and the type of vaccine administered did not demonstrate significant associations with the likelihood of post-vaccination COVID-19 infection in MS and NMOSD patients (p > 0.05 for all). There were no significant differences in the rates of adverse events in MS, NMOSD, and OND patients, except the second dose, where NMOSD patients had lower odds than OND patients (OR = 0.55, p = 0.019).

CONCLUSION

Although the safety profile of COVID-19 vaccination in MS and NMOSD was similar to that in OND, the rates of post-vaccination COVID-19 infection in MS and NMOSD seem higher than OND. These findings highlight the importance of regular serological monitoring and the potential advantages of supplementary vaccine doses in MS and NMOSD patients.

Immunogenicity of a seasonal influenza and a pneumococcal polysaccharide vaccine in multiple sclerosis patients under disease modifying therapies: A single-center prospective study

BACKGROUND

Immunogenicity of influenza and pneumococcal vaccines varies and requires further elucidation in patients with multiple sclerosis (MS) under treatment with disease-modifying therapies (DMTs).

METHODS

Adult MS patients who consented with vaccination after standard-of-care consultation by their treating physicians were enrolled. All received a single dose of an inactivated quadrivalent influenza vaccine and of the 23-valent pneumococcal vaccine. A blood sample was collected before and after four weeks of vaccination for measurement of antibodies against Influenza A, B and S. pneumoniae. Patients were followed-up for adverse events and MS relapse for 12 months.

RESULTS

One hundred and seventy-two patients (65.7 % female, mean age 42 ± 13 years old, mean MS duration 7.6 ± 7.2 years, 81.4 % under DMTs) were enrolled from November 2019 to March 2020. Antibody measurements were available for 151 patients. Seropositivity for anti-PPSV23 did not differ between baseline and at 4 weeks of follow-up (n = 56, 37.1 %). There was a significant increase of absolute antibody titers post-vaccination for both influenza A and B (p < 0.001). For Influenza A, seropositivity was evident for 57 (37.7 %) patients at 4 weeks compared to 19 (12.6 %) patients at baseline (pMcNemar < 0.001). For Influenza Β, 110 (72.8 %) seroconverted 4 weeks after vaccination compared to 12 (7.9 %) at baseline (pMcNemar < 0.001). Interferon and fumarate did not affect influenza seroconversion while rituximab was associated with lower titers. Mild local AEs (pain, edema) were observed in 23.8 %; no severe AE was reported. Thirty-four patients (19.8 %) had a relapse during the 12-month follow-up; none was attributed to the vaccination.

CONCLUSIONS

Seroconversion in MS patients on treatment was more frequent following influenza compared to PPSV23 vaccination. Rituximab had an effect on the height of the immune response. Better immunization coverage as well as future evaluation of the breadth of immune response elicited by immunization is necessary for these patients.

Immunosenescence and vaccine efficacy revealed by immunometabolic analysis of SARS-CoV-2-specific cells in multiple sclerosis patients

Disease-modifying therapies (DMT) administered to patients with multiple sclerosis (MS) can influence immune responses to SARS-CoV-2 and vaccine efficacy. However, data on the detailed phenotypic, functional and metabolic characteristics of antigen (Ag)-specific cells following the third dose of mRNA vaccine remain scarce. Here, using flow cytometry and 45-parameter mass cytometry, we broadly investigate the phenotype, function and the single-cell metabolic profile of SARS-CoV-2-specific T and B cells up to 8 months after the third dose of mRNA vaccine in a cohort of 94 patients with MS treated with different DMT, including cladribine, dimethyl fumarate, fingolimod, interferon, natalizumab, teriflunomide, rituximab or ocrelizumab. Almost all patients display functional immune response to SARS-CoV-2. Different metabolic profiles characterize antigen-specific-T and -B cell response in fingolimod- and natalizumab-treated patients, whose immune response differs from all the other MS treatments.

Efficacy of Accelerated Vaccination against Hbv to Achieve Antibody formation in Multiple Sclerosis Patients Receiving Anti-Cd20 Therapy

Aim

Ocrelizumab is a monoclonal antibody that has been approved for use in both relapsing-remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS). Since ocrelizumab acts on B cells, it also affects humoral immunity, thus reducing the vaccine response. In this study, we aimed to elucidate the relationship between the antibody response following rapid vaccination against hepatitis B virus (HBV) in multiple sclerosis (MS) patients receiving ocrelizumab treatment, and the time of vaccination.

Materials and Methods

A total of 220 MS patients were included in this retrospective analysis. The patients' baseline HBV serostatuses (HbsAg, Anti-HbsAb, Anti-HbcAb), previous drug history for MS, whether they were vaccinated against HBV in the past, vaccination status before or after ocrelizumab treatment, and protective antibody titers according to vaccination times, occult HBV incidence and initiation of antiviral treatment were evaluated.

Results

Forty-nine percent of MS patients using ocrelizumab were not vaccinated against HBV. The patients were divided into three groups according to their vaccination status as: individuals vaccinated in the past (7.3%, n = 16), vaccinated before treatment (4.5%, n = 10), and vaccinated after treatment (22.3%, n = 49). The antibody titers of the patients in the 6th month after ocrelizumab treatment were measured as 78 mIU/ml, 193 mIU/ml, and 0, respectively. The number of patients with occult HBV infection was 38.

Conclusion

In patients with a suspected diagnosis of MS, HBV serostatus should be evaluated at the beginning and if necessary, patients should be vaccinated in the early period. Vaccinating patients at least 1 month before initiating multiple sclerosis treatment is more effective in terms of protective antibody formation.

Summary of Safety and Efficacy of COVID Vaccination in Patients with Multiple Sclerosis

BACKGROUND

The SARS-CoV-2 pandemic represents one of the most challenging issues that have recently influenced everyday life in countries all over the world. Understanding the risk of this disease is of high importance in patients with multiple sclerosis (MS) as they represent a vulnerable population through their treatment with disease-modifying therapies (DMTs). Infective episodes may trigger relapses and lead to deterioration of the health condition.

SUMMARY

Vaccination is an important preventive measure against infectious diseases. In MS patients, concerns have been raised about the effectiveness of vaccines in patients on various immunomodulatory drugs and about their possible adverse effects including impairment of neurological functions. The objectives of this article were to summarize the current knowledge on immune responses to the COVID-19 vaccines and their safety in MS patients and to provide practical guidance based on the data available to date.

KEY MESSAGES

Although MS is not associated with a higher risk of COVID-19, this infection can trigger relapses or pseudo-relapses. Vaccines against SARS-CoV-2 are recommended for all MS patients who are not in the active phase of the disease, despite the fact that there is still a lack of long-term reliable data on the effectiveness and safety of vaccines against COVID-19. Some DMTs can reduce vaccine humoral responses, but might still provide some protection and adequate T-cell response. To optimize the effectiveness of vaccination, the ideal timing of vaccine application and DMTs dosing regimen is crucial.

Response of COVID-19 vaccination in multiple sclerosis patients following disease-modifying therapies: A meta-analysis

Background

COVID-19 vaccination is recommended for patients with multiple sclerosis (pwMS), while disease-modifying therapies (DMTs) may influence the efficacy of SARS-CoV-2 vaccines in this population. Thus, we conducted a meta-analysis to evaluate the impact of DMTs on immune response to COVID-19 vaccines in pwMS.

Methods

Literature search from December 1, 2019 to March 31, 2022 was performed in PubMed, MedRxiv, Embase and Cochrane Library. The risk of impaired response to vaccination in pwMS receiving DMTs was estimated in odds ratios (ORs) using random-effects method.

Findings

A total of 48 studies comprising 6860 pwMS were included. Overall, pwMS with anti-CD20 (OR=0.02, 95% CI: 0.01-0.03) and sphingosine-1-phosphate receptor modulator (S1PRM) (OR=0.03, 95% CI: 0.01-0.06) treatments had attenuated serologic response after full vaccination compared with those without DMTs. Additionally, pwMS vaccinated within six months since last anti-CD20 therapy were at significantly higher risk of blunted response compared with those receiving anti-CD20 therapy more than six months prior to vaccination (P = 0.001). We found no significant associations between other treatments (including IFN-β, GA, DMF, TERI, NTZ, CLAD, and ALE) and humoral response to SARS-CoV-2 vaccines in pwMS. As for T-cell response, no significant difference was found between pwMS on anti-CD20 and those without DMTs after vaccination, while S1PRM was marginally associated with impaired cellular response (P = 0.03).

Interpretation

Our findings suggested that routine serological monitoring may be required for pwMS on anti-CD20 and S1PRMs after SARS-CoV-2 vaccination and highlighted the benefits of a booster dose. The effect of cellular response and optimal interval from last anti-CD20 treatment to vaccination should be further addressed.

Funding

This study was supported by Natural Science Foundation of Shanghai (21ZR1433000).