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Sim TM, Lahiri M, Ma M, Cheung PPM, Mak A, Fong W, Angkodjojo S, Xu C, Kong KO, Arkachaisri T, Phang KF, Tan TC, Yap QV, Chan YH, Sriranganathan M, Chuah TY, Roslan NE, Poh YJ, Law A, Santosa A, Tay SH. Latent Class Analysis Identifies Distinct Phenotypes of Systemic Lupus Erythematosus Predictive of Flares after mRNA COVID-19 Vaccination: Results from the Coronavirus National Vaccine Registry for ImmuNe Diseases SINGapore (CONVIN-SING). Vaccines (Basel) 2023; 12:29. [PMID: 38250842 PMCID: PMC10819486 DOI: 10.3390/vaccines12010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/03/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
We recently reported that messenger ribonucleic acid (mRNA) coronavirus disease 2019 (COVID-19) vaccination was associated with flares in 9% of patients with systemic lupus erythematosus (SLE). Herein, we focused our analysis on patients from a multi-ethnic Southeast Asian lupus cohort with the intention of identifying distinct phenotypes associated with increased flares after mRNA COVID-19 vaccination. METHODS Six hundred and thirty-three SLE patients from eight public healthcare institutions were divided into test and validation cohorts based on healthcare clusters. Latent class analysis was performed based on age, ethnicity, gender, vaccine type, past COVID-19 infection, interruption of immunomodulatory/immunosuppressive treatment for vaccination, disease activity and background immunomodulatory/immunosuppressive treatment as input variables. Data from both cohorts were then combined for mixed effect Cox regression to determine which phenotypic cluster had a higher risk for time to first SLE flare, adjusted for the number of vaccine doses. RESULTS Two clusters were identified in the test (C1 vs. C2), validation (C1' vs. C2') and combined (C1″ vs. C2″) cohorts, with corresponding clusters sharing similar characteristics. Of 633 SLE patients, 88.6% were female and there was multi-ethnic representation with 74.9% Chinese, 14.2% Malay and 4.6% Indian. The second cluster (C2, C2' and C2″) was smaller compared to the first. SLE patients in the second cluster (C2 and C2') were more likely to be male, non-Chinese and younger, with higher baseline disease activity. The second cluster (C2″) had more incident flares (hazard ratio = 1.4, 95% confidence interval 1.1-1.9, p = 0.014) after vaccination. A higher proportion of patients in C2″ had immunomodulatory/immunosuppressive treatment interruption for vaccination as compared to patients in C1″ (6.6% vs. 0.2%) (p < 0.001). CONCLUSION We identified two distinct phenotypic clusters of SLE with different patterns of flares following mRNA COVID-19 vaccination. Caution has to be exercised in monitoring for post-vaccination flares in patients with risk factors for flares such as non-Chinese ethnicity, young age, male gender and suboptimal disease control at the time of vaccination.
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Affiliation(s)
- Tao Ming Sim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore; (T.M.S.)
| | - Manjari Lahiri
- Division of Rheumatology, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Level 10, NUHS Tower Block, Singapore 119228, Singapore; (M.M.); (A.S.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (W.F.); (K.F.P.)
| | - Margaret Ma
- Division of Rheumatology, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Level 10, NUHS Tower Block, Singapore 119228, Singapore; (M.M.); (A.S.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (W.F.); (K.F.P.)
| | - Peter Pak-Moon Cheung
- Division of Rheumatology, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Level 10, NUHS Tower Block, Singapore 119228, Singapore; (M.M.); (A.S.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (W.F.); (K.F.P.)
| | - Anselm Mak
- Division of Rheumatology, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Level 10, NUHS Tower Block, Singapore 119228, Singapore; (M.M.); (A.S.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (W.F.); (K.F.P.)
| | - Warren Fong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (W.F.); (K.F.P.)
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore 169608, Singapore
- Duke-NUS Medical School, Singapore 169857, Singapore;
| | - Stanley Angkodjojo
- Rheumatology Service, Department of General Medicine, Sengkang General Hospital, Singapore 544886, Singapore
| | - Chuanhui Xu
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore; (C.X.)
| | - Kok Ooi Kong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore; (C.X.)
| | - Thaschawee Arkachaisri
- Duke-NUS Medical School, Singapore 169857, Singapore;
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore 229899, Singapore
| | - Kee Fong Phang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (W.F.); (K.F.P.)
- Chronic Programme, Alexandra Hospital, Singapore 159964, Singapore
| | - Teck Choon Tan
- Division of Rheumatology, Department of General Medicine, Khoo Teck Puat Hospital, Singapore 768828, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore; (Q.V.Y.); (Y.H.C.)
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore; (Q.V.Y.); (Y.H.C.)
| | - Melonie Sriranganathan
- Division of Rheumatology, Department of Medicine, Changi General Hospital, Singapore 529889, Singapore
| | - Tyng Yu Chuah
- Rheumatology Service, Department of General Medicine, Sengkang General Hospital, Singapore 544886, Singapore
| | - Nur Emillia Roslan
- Rheumatology Service, Department of General Medicine, Sengkang General Hospital, Singapore 544886, Singapore
| | - Yih Jia Poh
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore 169608, Singapore
| | - Annie Law
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore 169608, Singapore
- Duke-NUS Medical School, Singapore 169857, Singapore;
| | - Amelia Santosa
- Division of Rheumatology, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Level 10, NUHS Tower Block, Singapore 119228, Singapore; (M.M.); (A.S.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (W.F.); (K.F.P.)
| | - Sen Hee Tay
- Division of Rheumatology, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Level 10, NUHS Tower Block, Singapore 119228, Singapore; (M.M.); (A.S.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (W.F.); (K.F.P.)
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Fong W, Woon TH, Chew LC, Low A, Law A, Poh YJ, Yeo SI, Leung YY, Ma M, Santosa A, Kong KO, Xu C, Teng GG, Mak A, Tay SH, Chuah TY, Roslan NE, Angkodjojo S, Phang KF, Sriranganathan M, Tan TC, Cheung P, Lahiri M. Prevalence and factors associated with flares following COVID-19 mRNA vaccination in patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis: a national cohort study. Adv Rheumatol 2023; 63:38. [PMID: 37528453 DOI: 10.1186/s42358-023-00316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 07/19/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVE To determine prevalence and factors associated with flares post Coronavirus disease 2019 (COVID-19) mRNA vaccination in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (SpA). METHODS A retrospective multi-centre study was conducted (January 2021 to February 2022). Data were collected during index visit, defined as first post-vaccine visit in which the patient had a physician-defined flare, or if at least 3 months had elapsed since first vaccine dose, whichever came first. Factors associated with flares were identified using mixed effects Cox regression and expressed as hazard ratio (HR) and 95% confidence interval (CI). RESULTS Total of 2377 patients were included (1563 RA, 415 PsA and 399 SpA). Among patients with RA, PsA and SpA, 21.3%, 24.1% and 21.8% experienced a flare respectively. Of those who experienced a flare, only 10.2%, 11.0% and 14.9% were severe in patients with RA, PsA and SpA respectively. Patients with low or moderate/high disease were more likely to flare compared to those in remission in patients with RA only (HR: 1.68, 95% CI 1.22-2.31; HR: 2.28, 95% CI 1.50-3.48, respectively). Receiving the Moderna vaccine was associated with a higher HR of flare compared to the Pfizer vaccine in patients with PsA only (HR: 2.21, 95% CI 1.20-4.08). Patients who had two vaccine doses were found to be less likely to flare (HR: 0.08, 95% CI 0.06-0.10). HRs of flares were not significantly different among RA, PsA and SpA. CONCLUSION About one-fifth of patients experienced a disease flare post COVID-19 mRNA vaccination, but most flares were non-severe. Patients with active disease prior to vaccination should be monitored closely for disease flares, especially in patients with RA.
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Affiliation(s)
- Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia, Level 4, 20 College Road, Singapore, 169856, Singapore.
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Rheumatology, Duke-NUS Medical School, Singapore, Singapore.
| | - Ting Hui Woon
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia, Level 4, 20 College Road, Singapore, 169856, Singapore
| | - Li-Ching Chew
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia, Level 4, 20 College Road, Singapore, 169856, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Rheumatology, Duke-NUS Medical School, Singapore, Singapore
| | - Andrea Low
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia, Level 4, 20 College Road, Singapore, 169856, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Rheumatology, Duke-NUS Medical School, Singapore, Singapore
| | - Annie Law
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia, Level 4, 20 College Road, Singapore, 169856, Singapore
- Rheumatology, Duke-NUS Medical School, Singapore, Singapore
| | - Yih Jia Poh
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia, Level 4, 20 College Road, Singapore, 169856, Singapore
| | - Siaw Ing Yeo
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia, Level 4, 20 College Road, Singapore, 169856, Singapore
| | - Ying Ying Leung
- Department of Rheumatology and Immunology, Singapore General Hospital, Academia, Level 4, 20 College Road, Singapore, 169856, Singapore
- Rheumatology, Duke-NUS Medical School, Singapore, Singapore
| | - Margaret Ma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Amelia Santosa
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Kok Ooi Kong
- Rheumatology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chuanhui Xu
- Rheumatology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Gim Gee Teng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Anselm Mak
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sen Hee Tay
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Tyng Yu Chuah
- Rheumatology, Sengkang General Hospital, Singapore, Singapore
| | | | | | - Kee Fong Phang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Medicine, Alexandra Hospital, Singapore, Singapore
| | | | - Teck Choon Tan
- Rheumatology, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Peter Cheung
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Manjari Lahiri
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
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3
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Xu C, Lahiri M, Santosa A, Chew LC, Angkodjojo S, Sriranganathan M, Fong W, Arkachaisri T, Suresh E, Kong KO, Lateef A, Lee TH, Leong KH, Low A, Tan TC, Leung YY. Recommendations for enhanced primary series (third dose) COVID-19 vaccination for people with rheumatic diseases: Chapter of Rheumatologists, College of Physicians, Singapore. Singapore Med J 2023:382525. [PMID: 37530384 DOI: 10.4103/singaporemedj.smj-2022-070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Introduction This review aims to provide evidence-based recommendations for an enhanced primary series (third dose) coronavirus disease 2019 (COVID-19) vaccination in people with rheumatic diseases (PRDs) in the local and regional context. Methods Literature reviews were performed regarding the necessity, efficacy, safety and strategies for enhanced primary series COVID-19 vaccination in PRDs. Recommendations were developed based on evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence was synthesised by eight working group members, and the consensus was achieved by a Delphi method with nine members of an expert task force panel. Results Two graded recommendations and one ungraded position statement were developed. PRDs have impaired immunogenicity from the COVID-19 vaccine and are at an increased risk of postvaccine breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and poor clinical outcomes, compared to the general population. We strongly recommend that PRDs on immunomodulatory drugs be offered a third dose of the messenger RNA (mRNA) vaccine as part of an enhanced primary series, after the standard two-dose regimen. We conditionally recommend that the third dose of mRNA vaccine against SARS-CoV-2 be given at least 4 weeks after the second dose or as soon as possible thereafter. There is insufficient data to inform whether the third mRNA vaccine should be homologous or heterologous in PRDs. Conclusion These recommendations that were developed through evidence synthesis and formal consensus process provide guidance for an enhanced primary series COVID-19 vaccination in PRDs.
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Affiliation(s)
- Chuanhui Xu
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Manjari Lahiri
- Division of Rheumatology, Department of Medicine, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Amelia Santosa
- Division of Rheumatology, Department of Medicine, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Li-Ching Chew
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Department of Rheumatology and Immunology, Singapore General Hospital; Duke-NUS School of Medicine, Sengkang General Hospital, Singapore
| | - Stanley Angkodjojo
- Department of General Medicine (Rheumatology), Sengkang General Hospital, Singapore
| | | | - Warren Fong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Department of Rheumatology and Immunology, Singapore General Hospital; Duke-NUS School of Medicine, Sengkang General Hospital, Singapore
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Ernest Suresh
- Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Kok Ooi Kong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Aisha Lateef
- Division of Rheumatology, Department of Medicine, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Department of Medicine, Woodlands Health, Singapore
| | - Tau Hong Lee
- National Centre for Infectious Diseases, Singapore
| | | | - Andrea Low
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Department of Rheumatology and Immunology, Singapore General Hospital; Duke-NUS School of Medicine, Sengkang General Hospital, Singapore
| | - Teck Choon Tan
- Division of Rheumatology, Department of Medicine, Khoo Teck Puat Hospital, Singapore
| | - Ying-Ying Leung
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Department of Rheumatology and Immunology, Singapore General Hospital; Duke-NUS School of Medicine, Sengkang General Hospital, Singapore
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4
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Ma M, Santosa A, Fong W, Chew LC, Low AHL, Law A, Poh YJ, Yeo SI, Leung YY, Ng VWW, Koh JZE, Tay SH, Mak A, Teng GG, Xu C, Tang JGX, Kong KO, Angkodjojo S, Goh WR, Chuah TY, Roslan NE, Arkachaisri T, Teh KL, Sriranganathan M, Tan TC, Phang KF, Yap QV, Chan YH, Cheung PPM, Lahiri M. Post-mRNA vaccine flares in autoimmune inflammatory rheumatic diseases: Results from the COronavirus National Vaccine registry for ImmuNe diseases SINGapore (CONVIN-SING). J Autoimmun 2023; 134:102959. [PMID: 36473406 PMCID: PMC9705203 DOI: 10.1016/j.jaut.2022.102959] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Studies of flares of autoimmune inflammatory rheumatic diseases (AIIRD) after COVID-19 mRNA vaccination are limited by small sample size, short follow up or at risk of selection bias. METHODS A national retrospective cohort study of consecutive AIIRD patients ≥12 years old, across 8 hospitals who received at least one dose of a COVID-19 mRNA vaccine. Patients were included from the date of 1st vaccine dose and censored at the time of flare or on the date of the clinic visit at least 3 months from cohort entry, whichever came first. Predictors of flare were determined by Cox proportional hazards analysis. FINDINGS 4627 patients (73% Chinese, 71% female) of median (IQR) age 61 (48, 70) years were included; 42% Rheumatoid arthritis, 14% Systemic lupus erythematosus and 11% Psoriatic arthritis. 47% were in remission, 41% low disease activity, 10% moderate disease activity and 1% in high disease activity. 18% patients flared, of which 11.7% were within the 3-month period of interest. 11.8% patients improved. Median (IQR) time-to-flare was 60 (30, 114) days. 25% flares were self-limiting, 61% mild-moderate and 14% severe. Older patients (53-65 years and >66 years) had a lower risk of flare [HR 0.6 (95% CI 0.5-0.8) and 0.7 (0.6-0.8) respectively]. Patients with inflammatory arthritis and with active disease had a higher risk of flare [HR 1.5 (1.2-2.0) and 1.4 (1.2-1.6), respectively]. Treatment with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), immunosuppression and prednisolone was also associated with an increased risk of flare [HR 1.5 (1.1-2), 1.2 (1.1-1.4) and 1.5 (1.2-1.8) for prednisolone ≤7.5 mg respectively]. INTERPRETATION There was a moderately high rate of AIIRD flares after mRNA vaccination but also improvement in several patients. Severe flares and hospitalisation were rare. Thus, vaccination remains safe and highly recommended.
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Affiliation(s)
- Margaret Ma
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Amelia Santosa
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Warren Fong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Department of Rheumatology and Immunology, Singapore General Hospital, Singapore,Duke-NUS Medical School, Singapore
| | - Li-Ching Chew
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Department of Rheumatology and Immunology, Singapore General Hospital, Singapore,Duke-NUS Medical School, Singapore
| | - Andrea HL Low
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Department of Rheumatology and Immunology, Singapore General Hospital, Singapore,Duke-NUS Medical School, Singapore
| | - Annie Law
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore,Duke-NUS Medical School, Singapore
| | - Yih Jia Poh
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
| | - Siaw Ing Yeo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
| | - Ying Ying Leung
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore,Duke-NUS Medical School, Singapore
| | - Victoria WW Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joshua ZE Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sen Hee Tay
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anselm Mak
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gim Gee Teng
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Chronic Programme, Alexandra Hospital, Singapore
| | - Chuanhui Xu
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Johnston GX Tang
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Kok Ooi Kong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Stanley Angkodjojo
- Rheumatology Service, Department of General Medicine, Sengkang General Hospital, Singapore
| | - Wei-Rui Goh
- Rheumatology Service, Department of General Medicine, Sengkang General Hospital, Singapore
| | - Tyng Yu Chuah
- Rheumatology Service, Department of General Medicine, Sengkang General Hospital, Singapore
| | - Nur Emillia Roslan
- Rheumatology Service, Department of General Medicine, Sengkang General Hospital, Singapore
| | - Thaschawee Arkachaisri
- Duke-NUS Medical School, Singapore,Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Kai Liang Teh
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | | | - Teck Choon Tan
- Division of Rheumatology, Department of Medicine, Khoo Teck Puat Hospital, Singapore
| | - Kee Fong Phang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Chronic Programme, Alexandra Hospital, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Peter PM Cheung
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Manjari Lahiri
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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5
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Ma M, Santosa A, Kong KO, Xu C, Xiang JTG, Teng GG, Mak A, Tay SH, Ng VWW, Koh JZE, Fong W, Chew LC, Low A, Law A, Poh YJ, Yeo SI, Leung YY, Goh WR, Yu CT, Roslan NE, Angkodjojo S, Phang KF, Arkachaisri T, Sriranganathan M, Tan TC, Cheung P, Lahiri M. POS0200 POST-mRNA VACCINE FLARES IN AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES: INTERIM RESULTS FROM THE CORONAVIRUS NATIONAL VACCINE REGISTRY FOR IMMUNE DISEASES SINGAPORE (CONVIN-SING). Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundPublished data suggest no increased rate of flare of autoimmune inflammatory rheumatic diseases (AIIRD) after COVID-19 mRNA vaccination; however, the studies are limited by small sample size, short follow up or at risk of selection bias (voluntary physician reports or patient surveys).ObjectivesTo study flares of AIIRD within three months of the first dose of an anti-SARS-COV2 mRNA vaccine.MethodsA retrospective cohort study of consecutive AIIRD patients ≥ 12 years old, across six public hospitals in Singapore who received at least one dose of an mRNA (Pfizer/BioNTech or Moderna) vaccine. Data were censored at the first post-vaccine clinic visit when the patient had flared or if ≥ three months had elapsed since the first dose of the vaccine, whichever came first. Predictors of flare were determined by Cox proportional hazards analysis and time to flare was examined using a Nelson Aalen cumulative hazard estimate (Figure 1).Figure 1.Nelson-Aalen curve of flares over timeResults2339 patients (74% Chinese, 72% female) of median (IQR) age 64 (53, 71) years were included in the interim analysis (Table 1). 2112 (90%) had the Pfizer/BioNTech vaccine and 195 (8%) had Moderna, with a median (IQR) interval of 21 (21, 23) days between the two doses. The most common AIIRD diagnoses were Rheumatoid arthritis (1063, 45%), Psoriatic arthritis (296, 12.6%) and Systemic lupus erythematosus (SLE) (288, 12.3%). 186 (8%) were treated with biologics/ targeted disease modifying agents. 2125 (91%) patients were in low disease activity or remission. Treatment was interrupted for vaccination in only 18 (0.8%) patients. Seven (0.3%) patients had previous COVID-19 infection.Table 1.Patient characteristicsBaseline characteristicsNo flares(n = 1887, %)Flares within 0—3 months of 1st vaccine dose (n= 272, %)Flares outside of 0 – 3 months after 1st vaccine dose (n = 180, %)Age (median years, IQR)64 (53, 71)61 (50, 69)65 (55, 71)RaceChinese1386 (73)206 (76)129 (72)Malay193 (10)28 (10)20 (11)Indian195 (10)27 (10)26 (14)GenderFemale1367 (72)200 (74)117 (65)Vaccine typePfizer/BioNTech1713 (92)239 (90)160 (90)Moderna149 (8)28 (10)18 (10)DiagnosisRheumatoid Arthritis831 (44)139 (51)93 (52)Systemic Lupus Erythematosus269 (14)20 (7)9 (5)Psoriatic Arthritis225 (12)42 (15)29 (16)Spondyloarthropathies141 (7)21 (7)17 (9)Sjogren’s Syndrome114 (6)15 (6)8 (4)Systemic sclerosis94 (5)4 (1)6 (3)Baseline Physician Disease ActivityRemission1007 (53)99 (36)63 (35)Low Disease Activity731 (39)128 (47)97 (54)Moderate Disease Activity134 (7)40 (15)20 (11)High Disease Activity15 (1)5 (2)0452 (19%) flares were recorded during 9798.8 patient-months [4.6/100 patient-months, median (IQR) follow up duration 4.2 (3.3, 5.3) months], of which 272 (11.6%) patients flared within the 3-month period of interest and 180 (7.7%) flared outside of the 3-month period (Table 1). Median (IQR) time-to-flare was 40.5 (18, 56.6) days. 60 (22.1%) were mild and self-limiting, 170 (62.5%) were mild-moderate and 42 (15.4%) were severe. 190 (69.8%) of those who flared required escalation of treatment and 15 (5.5%) required hospital admission. 239 (10.2%) had improved disease activity after the vaccine.On multivariate Cox regression analysis, patients in the oldest age tertile [median (IQR) 74 (71, 79) years] were less likely to flare [HR 0.80 (95% CI 0.63, 1.00), p = 0.05] Patients with inflammatory arthritis (compared with connective tissue disease, vasculitis and others) and patients with baseline active disease were more likely to flare [HR 1.72 (95% CI 1.35, 2.20), p < 0.001 and 1.82 (95% CI 1.39, 2.39), p < 0.001 respectively]ConclusionThere was a moderately high rate of AIIRD flares after mRNA vaccination; however, there was no clustering of flares in the immediate post-vaccine period to suggest causality. Older patients were less likely to flare, while those with inflammatory arthritis and active disease at baseline were more likely to flare.Disclosure of InterestsMargaret Ma Grant/research support from: Support grant from multiple companies for the Singapore Biologics registry, Amelia Santosa Speakers bureau: Amgen Talk, Consultant of: Pfizer ad board, Kok Ooi Kong: None declared, Chuanhui Xu: None declared, Johnston Tang Gin Xiang: None declared, Gim Gee Teng Speakers bureau: Boehringer Ingleheim, Anselm Mak Speakers bureau: J&J and GSK, Grant/research support from: GSK - the supported studies programme, Sen Hee Tay: None declared, Victoria Wei Wen Ng: None declared, Joshua Zhi En Koh: None declared, Warren Fong Speakers bureau: speaker for Abbvie, DKSH, GSK, Novartis, Li-Ching Chew Speakers bureau: pfizer and Abbvie, Consultant of: Pfizer and Abbvie Advisory Board meeting, Grant/research support from: Abbvie educational grant for ultrasound conference, Andrea Low Speakers bureau: Boehringer Ingeilheim, Consultant of: Consultant/steering group committee for BI and J&J, annie law: None declared, Yih Jia Poh: None declared, Siaw Ing Yeo Grant/research support from: Multiple pharmaceutical companies for the support of the National Biologics Registry, Ying Ying Leung Speakers bureau: Abbvie, DKSH, Jassen, Novartis and Pfizer, Wei-Rui Goh: None declared, Chuah Tyng Yu: None declared, Nur Emillia Roslan: None declared, Stanley Angkodjojo Speakers bureau: Boehringer Ingeilheim, Consultant of: Abbvie and DKSH, Kee Fong Phang: None declared, Thaschawee Arkachaisri: None declared, Melonie Sriranganathan: None declared, Teck Choon TAN: None declared, Peter Cheung Consultant of: Ad board for Boehringer Ingleheim, novartis, janssen and abbvie, Grant/research support from: Novartis, Manjari Lahiri Speakers bureau: J&J, DSKH, Consultant of: DSKH, Gilead, Grant/research support from: Multiple pharma companies contributed to the Singapore Biologics registryNovartis
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Roy MTHM, Loh CH, Sriranganathan M, Takano Pena AM, Raghuram J. Idiopathic recurrent serositis-Off the beaten track. Respirol Case Rep 2021; 9:e0859. [PMID: 34667614 PMCID: PMC8506259 DOI: 10.1002/rcr2.859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/19/2021] [Accepted: 09/15/2021] [Indexed: 11/07/2022] Open
Abstract
A 63-year-old female presented with chest pain and fever, and was found to have recurrent pleuropericardial effusions. Extensive investigations including infection screen and serologies, autoimmune screen and pleural and pericardial biopsy revealed no secondary aetiologies. She was diagnosed with idiopathic recurrent serositis (IRS). Our patient developed rash to naproxen, so she was started on colchicine monotherapy and responded well clinically. A review of the literature demonstrated that pleuropericardial effusions are rare occurrences, with patients occasionally being perceived as a medical enigma. This case study recommends an approach to guide physicians in their diagnosis and management of patients with pleuropericardial syndrome. Our case had an inflammatory phenotype, either autoimmune or seronegative serositis of unclear aetiology, which was recurrent and required pharmacological treatment. While the treatment for IRS lies in combined therapy with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and colchicine, monotherapy with colchicine was effective in the treatment and preventing recurrence in our unique case.
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Affiliation(s)
| | - Chee Hong Loh
- Department of Respiratory and Critical Care MedicineChangi General HospitalSingapore
| | | | | | - Jagadesan Raghuram
- Department of Respiratory and Critical Care MedicineChangi General HospitalSingapore
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Sivera F, Andrés M, Carmona L, Kydd ASR, Moi J, Seth R, Sriranganathan M, van Durme C, van Echteld I, Vinik O, Wechalekar MD, Aletaha D, Bombardier C, Buchbinder R, Edwards CJ, Landewé RB, Bijlsma JW, Branco JC, Burgos-Vargas R, Catrina AI, Elewaut D, Ferrari AJL, Kiely P, Leeb BF, Montecucco C, Müller-Ladner U, Ostergaard M, Zochling J, Falzon L, van der Heijde DM. Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative. Ann Rheum Dis 2013; 73:328-35. [PMID: 23868909 PMCID: PMC3913257 DOI: 10.1136/annrheumdis-2013-203325] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We aimed to develop evidence-based multinational recommendations for the diagnosis and management of gout. Using a formal voting process, a panel of 78 international rheumatologists developed 10 key clinical questions pertinent to the diagnosis and management of gout. Each question was investigated with a systematic literature review. Medline, Embase, Cochrane CENTRAL and abstracts from 2010-2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, rheumatologists from 14 countries (Europe, South America and Australasia) developed national recommendations. After rounds of discussion and voting, multinational recommendations were formulated. Each recommendation was graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. Combining evidence and clinical expertise, 10 recommendations were produced. One recommendation referred to the diagnosis of gout, two referred to cardiovascular and renal comorbidities, six focused on different aspects of the management of gout (including drug treatment and monitoring), and the last recommendation referred to the management of asymptomatic hyperuricaemia. The level of agreement with the recommendations ranged from 8.1 to 9.2 (mean 8.7) on a 1-10 scale, with 10 representing full agreement. Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, enhancing their utility in clinical practice.
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Affiliation(s)
- Francisca Sivera
- Department Reumatologia, Hospital General Universitario de Elda, , Elda, Spain
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Maharaj RG, Rampersad J, Henry J, Khan KV, Koonj-Beharry B, Mohammed J, Rajhbeharrysingh U, Ramkissoon F, Sriranganathan M, Brathwaite B, Barclay S. Critical incidents contributing to the initiation of substance use and abuse among women attending drug rehabilitation centres in Trinidad and Tobago. W INDIAN MED J 2005; 54:51-8. [PMID: 15892391 DOI: 10.1590/s0043-31442005000100011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The aim of this study was to determine the critical incidents that contribute to the initiation of substance use and abuse among women in Trinidad and Tobago. Twenty women were randomly selected from 46 women currently attending 43 drug rehabilitation centres, Narcotics Anonymous and Alcoholics Anonymous groups in Trinidad and Tobago. In-depth semi-structured interviews using the critical incident technique were conducted. Interviews were recorded, transcribed and analyzed. Concepts, categories and themes were determined by team study and group discussion. The critical incidents that influenced women to initiate the use and abuse of substances fell into eight major themes: factors intrinsic to the individual woman, family factors, social and environmental factors, life stresses, relationship issues, abuse, peer pressure and substance use and abuse as a coping mechanism. The results imply that the factors contributing to the initiation of substance use and abuse among women in Trinidad and Tobago are many and complex. As such any attempt to address this issue requires a broad-based approach. Such an approach should address family use of such substances, societal acceptance of them, availability, the self-esteem of the individual woman and her ability to cope with peer and internal stresses.
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Affiliation(s)
- R G Maharaj
- Department of Paraclinical Sciences, Public Health and Primary Care Unit (Family Medicine), Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago, West Indies.
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