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Imran M, Ali S, Ibrahim AA, Amjad A, Tanveer A, Khalil S, Ali M, Abuelazm M. Effect of methotrexate hold on COVID-19 vaccine response in the patients with autoimmune inflammatory disorders: a systematic review and meta-analysis. Clin Rheumatol 2024:10.1007/s10067-024-07013-3. [PMID: 38802670 DOI: 10.1007/s10067-024-07013-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/08/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024]
Abstract
Immunosuppressants, such as methotrexate (MTX), can suppress the COVID-19 vaccine response in patients with autoimmune diseases. Thus, this study aims to evaluate the effects of MTX hold following COVID-19 vaccination on vaccine efficacy response. A systematic review and meta-analysis of relevant studies retrieved from Web of Science, SCOPUS, PubMed, and CENTRAL from inception until Oct 1, 2023, was conducted. Covidence was used to screen the eligible articles, and all relevant outcomes data were synthesized using risk ratios (RRs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs) in meta-analysis models within RevMan 5.4. PROSPERO ID: CRD42024511628. Four studies with a total of 762 patients with autoimmune inflammatory disorders were included. Holding MTX following the COVID-19 vaccination for approximately 2 weeks was associated with significantly higher antibody titer (SMD: 0.70, 95% CI [0.54, 0.87], P < 0.00001). However, the flare rate was significantly higher in the MTX hold group based on CDAI > 10 or DAS28-CRP > 1.2 either after 1st dose (RR: 2.49 with 95% CI [1.39, 4.47], P = 0.002) or 2nd dose (RR: 2.16 with 95% CI [1.37, 3.41], P = 0.0009) and self-reported disease flare (RR: 1.71 with 95% CI [1.35, 2.17], P < 0.00001). Holding MTX for 2 weeks after the COVID-19 vaccination resulted in significantly higher antibody titer but also had a higher disease flare rate, necessitating cautious clinical monitoring during this period. There is still a need to investigate safer MTX hold duration, considering patients' vulnerability to COVID-19, disease status, and demographics while adopting this strategy.
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Affiliation(s)
- Muhammad Imran
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan.
| | - Shujaat Ali
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
| | | | - Areeb Amjad
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
| | - Aiman Tanveer
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
| | - Saba Khalil
- Faculty of Medicine, Fatima Jinnah Medical University, Lahore, Pakistan
| | - Mansab Ali
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
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Kashiwado Y, Kimoto Y, Ohshima S, Sawabe T, Irino K, Nakano S, Hiura J, Yonekawa A, Wang Q, Doi G, Ayano M, Mitoma H, Ono N, Arinobu Y, Niiro H, Hotta T, Kang D, Shimono N, Akashi K, Takeuchi T, Horiuchi T. Immunosuppressive therapy and humoral response to third mRNA COVID-19 vaccination with a six-month interval in rheumatic disease patients. Rheumatology (Oxford) 2024; 63:725-733. [PMID: 37289506 DOI: 10.1093/rheumatology/kead275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVES To evaluate the long-term impact of immunosuppressive therapeutic agents on antibody response to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) mRNA vaccination in patients with autoimmune rheumatic diseases (AIRD) in order to propose a strategy for annual vaccination. METHODS This prospective multicentre cohort study evaluated the humoral response to second and third BNT162b2 and/or mRNA-1273 vaccines in 382 Japanese AIRD patients classified into 12 different medication groups and in 326 healthy controls (HCs). The third vaccination was administered six months after the second vaccination. Antibody titres were measured using the Elecsys Anti-SARS-CoV-2 S assay. RESULTS The seroconversion rate and antibody titres were lower in AIRD patients than in HCs 3-6 weeks after the second vaccination and 3-6 weeks after the third vaccination. Seroconversion rates were <90% after the third vaccination in patients receiving mycophenolate mofetil and rituximab. Antibody levels after the third vaccination were significantly lower in the groups prescribed TNF inhibitor with or without methotrexate, abatacept and rituximab or cyclophosphamide than those of HCs in a multivariate analysis adjusting for age, sex, and glucocorticoid dosage. The third vaccination induced an adequate humoral response in patients treated with sulfasalazine, bucillamine, methotrexate monotherapy, iguratimod, interleukin-6 inhibitors or calcineurin inhibitors including tacrolimus. CONCLUSIONS Repeated vaccinations in many immunosuppressed patients produced antibody responses similar to those observed in HCs. In contrast, annual vaccination in patients receiving TNF inhibitors, abatacept, mycophenolate mofetil and rituximab may require caution.
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Affiliation(s)
- Yusuke Kashiwado
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
| | - Shiro Ohshima
- Department of Clinical Research, Rheumatology and Allergology, Osaka Minami Medical Center, Osaka, Japan
| | - Takuya Sawabe
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital, Hiroshima, Japan
| | - Kensuke Irino
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital, Hiroshima, Japan
| | - Shota Nakano
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital, Hiroshima, Japan
| | - Junki Hiura
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
| | - Akiko Yonekawa
- Center for the Study of Global Infection, Kyushu University Hospital, Fukuoka, Japan
| | - Qiaolei Wang
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Goro Doi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Nobuyuki Ono
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Taeko Hotta
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Dongchon Kang
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Nobuyuki Shimono
- Center for the Study of Global Infection, Kyushu University Hospital, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology and Clinical Immunology, Keio University, Tokyo, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
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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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Serra López-Matencio JM, Vicente-Rabaneda EF, Alañón E, Aranguren Oyarzabal A, Martínez Fleta P, Castañeda S. COVID-19 Vaccination and Immunosuppressive Therapy in Immune-Mediated Inflammatory Diseases. Vaccines (Basel) 2023; 11:1813. [PMID: 38140217 PMCID: PMC10747214 DOI: 10.3390/vaccines11121813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/25/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
The COVID-19 vaccination program has probably been the most complex and extensive project in history until now, which has been a challenge for all the people involved in the planning and management of this program. Patients with immune-mediated inflammatory diseases (IMIDs) on immunosuppressive therapy have required special attention, not only because of the particular haste in carrying out the process but also because of the uncertainty regarding their response to the vaccines. We now have strong scientific evidence that supports the hypothesis that immunosuppressive therapy inhibits the humoral response to vaccines against other infectious agents, such as influenza, pneumococcus and hepatitis B. This has led to the hypothesis that the same could happen with the COVID-19 vaccine. Several studies have therefore already been carried out in this area, suggesting that temporarily discontinuing the administration of methotrexate for 2 weeks post-vaccination could improve the vaccine response, and other studies with various immunosuppressive drugs are in the same line. However, the fact of withholding or interrupting immunosuppressive therapy when dealing with COVID-19 vaccination remains unclear. On this basis, our article tries to compile the information available on the effect of immunosuppressant agents on COVID-19 vaccine responses in patients with IMIDs and proposes an algorithm for the management of these patients.
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Affiliation(s)
- José M. Serra López-Matencio
- Hospital Pharmacy Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.A.); (A.A.O.)
| | | | - Estefanía Alañón
- Hospital Pharmacy Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.A.); (A.A.O.)
| | - Ainhoa Aranguren Oyarzabal
- Hospital Pharmacy Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.A.); (A.A.O.)
| | - Pedro Martínez Fleta
- Immunology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain;
| | - Santos Castañeda
- Rheumatology Service, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain;
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5
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Motwani KK, Hashash JG, Farraye FA, Kappelman MD, Weaver KN, Zhang X, Long MD, Cross RK. Impact of Holding Immunosuppressive Therapy in Patients with Inflammatory Bowel Disease Around mRNA COVID-19 Vaccine Administration on Humoral Immune Response and Development of COVID-19 Infection. J Crohns Colitis 2023; 17:1681-1688. [PMID: 37232444 DOI: 10.1093/ecco-jcc/jjad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND AND AIMS The BNT162b2 and mRNA-1273 COVID-19 vaccines are efficacious in patients with inflammatory bowel disease; but there is a lack of data examining if holding immunosuppressive therapy around vaccination improves immune response. We studied the effect of holding IBD medications around the time of vaccination on antibody response and breakthrough COVID-19 infection. METHODS Partnership to Report Effectiveness of Vaccination in populations Excluded from iNitial Trials of COVID is a prospective cohort of individuals with IBD receiving COVID-19 vaccination. Quantitative measurement of anti-receptor binding domain IgG antibodies to SARS-CoV-2 was performed 8 weeks after completing a vaccination series. RESULTS A total of 1854 patients were included; 59% were on anti-tumour necrosis factor [TNF] [10% of these on combination therapy], 11% on vedolizumab, and 14% on ustekinumab; 11% of participants held therapy before or after vaccine administration for at least 2 weeks. Antibody levels were similar in participants continuing versus holding anti-TNF monotherapy before or after the second vaccine [BNT162b2: 10 μg/mL vs 8.9 μg/mL; mRNA-1273: 17.5 μg/mL vs 14.5 μg/mL]. Comparable results were seen in those on combination therapy. Antibody titres in those on ustekinumab or vedolizumab were higher compared with anti-TNF users, but there was no significant difference if the drug was held or continued [BNT162b2: 22.5 μg/mL vs 23 μg/mL; mRNA-1273: 88 μg/mL vs 51 μg/mL]. Holding therapy was not associated with decreased rate of COVID-19 infection compared with those not holding therapy [BNT162b2: 28% vs 29%; mRNA-1273: 19% vs 31%]. CONCLUSION We recommend continuing IBD medications while receiving mRNA COVID-19 vaccination without interruption.
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Affiliation(s)
- Kiran K Motwani
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jana G Hashash
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Francis A Farraye
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Michael D Kappelman
- Department of Pediatrics, Division of Gastroenterology, University of North Carolina Chapel Hill, NC, USA
| | - Kimberly N Weaver
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina Chapel Hill, NC, USA
| | - Xian Zhang
- Department of Pediatrics, Division of Gastroenterology, University of North Carolina Chapel Hill, NC, USA
| | - Millie D Long
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina Chapel Hill, NC, USA
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, MD, USA
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6
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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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7
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Finckh A, Ciurea A, Raptis CE, Rubbert-Roth A. Susceptibility to COVID-19 and Immunologic Response to Vaccination in Patients With Immune-Mediated Inflammatory Diseases. J Infect Dis 2023; 228:S13-S23. [PMID: 37539758 PMCID: PMC10401619 DOI: 10.1093/infdis/jiad148] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/06/2023] [Indexed: 08/05/2023] Open
Abstract
Immune-mediated inflammatory diseases (IMIDs) are a highly heterogeneous group of diseases that share a common etiology of immune dysregulation, such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis, among others. It is estimated that the prevalence of IMIDs ranges between 5% and 7% in developed countries. As current management of IMIDs includes the use of immunomodulatory medications, the resulting weakened immune response can increase the risk of infection, including with SARS-CoV-2 (the causative agent of COVID-19) and reduce response to vaccination, placing these individuals at continued risk of severe outcomes from COVID-19. In this article, we summarize the current literature related to COVID-19 outcomes and the immunogenicity and reactogenicity of COVID-19 mRNA vaccination among patients with rheumatologically dominated IMIDs, as well as the effect of immunomodulatory therapies on these outcomes. We conclude by providing current COVID-19 vaccination recommendations for individuals with IMID.
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Affiliation(s)
- Axel Finckh
- Division of Rheumatology, Geneva University Hospitals, Geneva, Switzerland
- Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Adrian Ciurea
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Andrea Rubbert-Roth
- Correspondence: A. Rubbert-Roth, MD, Division of Rheumatology, Cantonal Hospital St. Gallen, Rorschacherstr 95, 9007 St. Gallen, Switzerland ()
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8
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Habermann E, Frommert LM, Ghannam K, Nguyen My L, Gieselmann L, Tober-Lau P, Klotsche J, Arumahandi de Silva AN, Ten Hagen A, Zernicke J, Kurth F, Sander LE, Klein F, Burmester GR, Biesen R, Albach FN. Performance of commercial SARS-CoV-2 wild-type and Omicron BA.1 antibody assays compared with pseudovirus neutralization tests. J Clin Virol 2023; 165:105518. [PMID: 37354690 DOI: 10.1016/j.jcv.2023.105518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/12/2023] [Accepted: 06/05/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Commercially available ELISA-based antibody tests are used to approximate vaccination success against SARS-CoV-2 in at-risk patients, but it is unclear whether they correlate with neutralization of the Omicron variant. METHODS 269 serum samples of a cohort of 44 non-immunosuppressed participants and 65 MTX-treated rheumatic patients taken before and after COVID-19 booster vaccinations were measured using COVID-19 antibody testing systems with wild-type and Omicron BA.1 antigens developed by three different manufacturers (surrogate virus neutralization test cPass, and binding antibody tests QuantiVac and SeraSpot), as well as with a pseudovirus neutralization test (pVNT). The pVNT was considered the gold standard for determining the presence and level of anti-SARS-CoV-2 antibodies. RESULTS All three wild-type ELISAs showed excellent test performance compared with wild-type neutralization in pVNT. However, out of 56 samples without Omicron BA.1 neutralization in pVNT, 71.4% showed positive results in at least one and 28.6% in all three wild-type ELISAs at the manufacturer-defined cut-offs. Omicron ELISAs showed either decreased specificity (57.1% and 55.4% for binding ELISAs) or sensitivity (51.2% in cPass) compared to Omicron neutralization in pVNT. The proportion of any false positive results among all samples decreased from 26.5% before to 3.2% after booster vaccination, however binding antibody test specificities remained below 70%. CONCLUSIONS We found a poorer test performance of new Omicron antibody test systems compared to wild-type tests in detecting neutralizing antibodies against the corresponding SARS-CoV-2 variants. Decisions for booster vaccination or passive immunization of at-risk patients should not be based solely on antibody test results.
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Affiliation(s)
- E Habermann
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - L M Frommert
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - K Ghannam
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - L Nguyen My
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - L Gieselmann
- Laboratory of Experimental Immunology, Institute of Virology, University Hospital Cologne, Cologne, Germany
| | - P Tober-Lau
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - J Klotsche
- German Rheumatism Research Center Berlin - a Leibniz Institute (DRFZ), Berlin, Germany
| | - A N Arumahandi de Silva
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - A Ten Hagen
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - J Zernicke
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - F Kurth
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - L E Sander
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - F Klein
- Laboratory of Experimental Immunology, Institute of Virology, University Hospital Cologne, Cologne, Germany
| | - G R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - R Biesen
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - F N Albach
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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9
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Durez P, Combe B. Should we stop methotrexate or not for vaccination? RMD Open 2023; 9:rmdopen-2022-002798. [PMID: 37015758 PMCID: PMC10083515 DOI: 10.1136/rmdopen-2022-002798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/18/2023] [Indexed: 04/06/2023] Open
Affiliation(s)
- Patrick Durez
- Rheumatology, Cliniques Universitaires Saint-Luc - Université catholique de Louvain (UCLouvain), Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
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10
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Tedeschi SK, Solomon DH, Chen Y, Ellrodt J, Whelan MG, Stratton J, Hayashi K, Whiteman NB, Chen L, Adejoorin I, Marks KE, Gomez-Rivas E, Rao DA, Jonsson AH, Wesemann DR. Humoral and cellular immune responses in persons with rheumatoid arthritis after a third dose of mRNA COVID-19 vaccine. Semin Arthritis Rheum 2023; 59:152177. [PMID: 36796211 PMCID: PMC9911151 DOI: 10.1016/j.semarthrit.2023.152177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/18/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Disease-modifying anti-rheumatic drugs (DMARDs) that treat rheumatoid arthritis (RA) may reduce immune responses to COVID-19 vaccination. We compared humoral and cell-mediated immunity before and after a 3rd dose of mRNA COVID vaccine in RA subjects. METHODS RA patients that received 2 doses of mRNA vaccine enrolled in an observational study in 2021 before receiving a 3rd dose. Subjects self-reported holding or continuing DMARDs. Blood samples were collected pre- and 4 weeks after the 3rd dose. 50 healthy controls provided blood samples. Humoral response was measured with in-house ELISA assays for anti-Spike IgG (anti-S) and anti-receptor binding domain IgG (anti-RBD). T cell activation was measured after stimulation with SARS-CoV-2 peptide. Spearman's correlations assessed the relationship between anti-S, anti-RBD, and frequencies of activated T cells. RESULTS Among 60 subjects, mean age was 63 years and 88% were female. 57% of subjects held at least 1 DMARD around the 3rd dose. 43% (anti-S) and 62% (anti-RBD) had a normal humoral response at week 4, defined as ELISA within 1 standard deviation of the healthy control mean. No differences in antibody levels were observed based on holding DMARDs. Median frequency of activated CD4 T cells was significantly greater post- vs. pre-3rd dose. Changes in antibody levels did not correlate with change in frequency of activated CD4 T cells. CONCLUSION Virus-specific IgG levels significantly increased in RA subjects using DMARDs after completing the primary vaccine series, though fewer than two-thirds achieved a humoral response like healthy controls. Humoral and cellular changes were not correlated.
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Affiliation(s)
- Sara K Tedeschi
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States.
| | - Daniel H Solomon
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Yuezhou Chen
- Department of Medicine, Harvard Medical School, Boston, MA, United States; Division of Allergy and Immunology, Division of Genetics, Brigham and Women's Hospital, Boston, MA, United States
| | - Jack Ellrodt
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States
| | - Mary Grace Whelan
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States
| | - Jacklyn Stratton
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States
| | - Keigo Hayashi
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States
| | - Noah Benjamin Whiteman
- Division of Allergy and Immunology, Division of Genetics, Brigham and Women's Hospital, Boston, MA, United States
| | - Lin Chen
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States
| | - Ifeoluwakiisi Adejoorin
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States
| | - Kathryne E Marks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Emma Gomez-Rivas
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States
| | - Deepak A Rao
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - A Helena Jonsson
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Duane R Wesemann
- Department of Medicine, Harvard Medical School, Boston, MA, United States; Division of Allergy and Immunology, Division of Genetics, Brigham and Women's Hospital, Boston, MA, United States; Ragon Institute of MGH, MIT, and Harvard, United States
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11
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Managing immunosuppression in vasculitis patients in times of COVID-19. Rheum Dis Clin North Am 2023. [PMCID: PMC10011035 DOI: 10.1016/j.rdc.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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12
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Tran AP, Tassone DF, Ding NS, Nossent J. Antibody response to the COVID-19 ChAdOx1nCov-19 and BNT162b vaccines after temporary suspension of DMARD therapy in immune-mediated inflammatory disease: an extension study (RESCUE 2). RMD Open 2023; 9:rmdopen-2022-002871. [PMID: 36863751 PMCID: PMC9990163 DOI: 10.1136/rmdopen-2022-002871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/01/2023] [Indexed: 03/04/2023] Open
Abstract
The persistence of immunogenicity in patients with immune-mediated inflammatory diseases (IMID) on disease-modifying antirheumatic therapy (DMARD) has been less well studied. This extension study evaluates the SARS-CoV2 antibody decay kinetics 6 months following two doses of ChAdO1nCov-19 (AZ) and BNT162b (Pfizer) and subsequent response following an mRNA booster. RESULTS: 175 participants were included. Six months after initial AZ vaccination, 87.5%, 85.4% and 79.2% (p=0.756) in the withhold, continue and control groups remained seropositive compared with 91.4%, 100% and 100% (p=0.226), respectively, in the Pfizer group. Both vaccine groups developed robust humoral immune responses following a booster with seroconversion rates being 100% for all three intervention categories. The mean SARS-CoV-2 antibody levels were significantly lower in the targeted synthetic DMARD (tsDMARD) group that continued therapy compared with the control (2.2 vs 4.8 U/mL, p=0.010). The mean time interval until loss of protective antibodies in the IMID group was 61 days for the AZ and 137.5 days for the Pfizer vaccine. Within each DMARD class the interval until loss of protective antibody titres in the csDMARD, bDMARD and tsDMARD groups were 68.3, 71.8 and 64.0 days in the AZ group and 185.5, 137.5 and 116.0 days in the Pfizer group, respectively. CONCLUSION: Antibody persistence was longer in the Pfizer group due to a higher peak antibody level following second vaccination with levels of protection in IMID on DMARD therapy similar to controls except in those on tsDMARDs where it was lower. A third mRNA vaccine booster can restore immunity in all groups.
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Affiliation(s)
- Ai Phuong Tran
- Department of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia .,St John of God Private Hospital, Murdoch, Western Australia, Australia
| | - D F Tassone
- The University of Melbourne, Melbourne, Victoria, Australia.,Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - N S Ding
- The University of Melbourne, Melbourne, Victoria, Australia.,Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Johannes Nossent
- Rheumatology Section, School of Medicine, University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Crawley, Western Australia, Australia.,Rheumatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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13
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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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14
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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: 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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15
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ten Hagen A, Hermann S, Habermann E, Frommert LM, Arumahandi de Silva AN, Scholz V, Ghannam K, Klotsche J, Zernicke J, Alexander T, Burmester GR, Albach FN, Biesen R. Improvement of humoral immunity by repeated dose-intensified COVID-19 vaccinations in primary non- to low-responders and B cell deficient rheumatic disease patients. J Autoimmun 2023; 135:102996. [PMID: 36642057 PMCID: PMC9826996 DOI: 10.1016/j.jaut.2023.102996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/21/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine whether repeated, dose-intensified mRNA vaccinations against COVID-19 increase humoral immunity in previously low-responding patients with autoimmune rheumatic diseases (AIRD), including rituximab-treated and B cell depleted patients. METHODS Of 308 AIRD patients receiving basic immunization, 98 had a low serological response against SARS-CoV-2 with a neutralizing capacity of < 70% using surrogate neutralization assay. 38 patients received a third vaccination with 30 μg BNT162b2 16 weeks after second vaccination. If neutralizing serum capacity was below 70% four weeks after the last vaccination, then the fourth vaccination (n = 19) and the fifth (n = 4) vaccination with 100 μg mRNA-1273 took place eight weeks after the last vaccination. RESULTS Each of the three booster vaccinations resulted in a significant increase of mean serum neutralizing capacity (3rd: Δ = 42%, p < 0.001; 4th: Δ = 19%, p = 0.049 and 5th: Δ = 51%, p = 0.043) and produced a significant proportion of high-responders (3rd: 34%; 4th: 32% and 5th: 75%). Low B cell counts (p = 0.047), lower previous antibody response (p < 0.001) and rituximab therapy (p = 0.021) were negatively associated with successful response to the third but not to the fourth vaccination. Remarkably, substantial increases in neutralization capacity of up to 99% were observed after repeated vaccinations in B cell depleted patients. CONCLUSION AIRD patients with low humoral response benefited from up to three repeated dose-intensified mRNA booster vaccinations - despite low B cell count and previous rituximab therapy. Each additional vaccination substantially reduced the number of low-responding, vulnerable patients.
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Affiliation(s)
- Alexander ten Hagen
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sandra Hermann
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Elisa Habermann
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Maria Frommert
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Amanthi Nadira Arumahandi de Silva
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Veronika Scholz
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Khetam Ghannam
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jens Klotsche
- Epidemiology Unit, German Rheumatism Research Center Berlin – a Leibniz Institute (DRFZ), Berlin, Germany
| | - Jan Zernicke
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gerd-R. Burmester
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fredrik N. Albach
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robert Biesen
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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16
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Alexopoulos H, Trougakos IP, Dimopoulos MA, Terpos E. Clinical usefulness of testing for severe acute respiratory syndrome coronavirus 2 antibodies. Eur J Intern Med 2023; 107:7-16. [PMID: 36379820 PMCID: PMC9647045 DOI: 10.1016/j.ejim.2022.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/11/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022]
Abstract
In the COVID-19 pandemic era, antibody testing against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has proven an invaluable tool and herein we highlight some of the most useful clinical and/or epidemiological applications of humoral immune responses recording. Anti-spike circulating IgGs and SARS-CoV-2 neutralizing antibodies can serve as predictors of disease progression or disease prevention, whereas anti-nucleocapsid antibodies can help distinguishing infection from vaccination. Also, in the era of immunotherapies we address the validity of anti-SARS-CoV-2 antibody monitoring post-infection and/or vaccination following therapies with the popular anti-CD20 monoclonals, as well as in the context of various cancers or autoimmune conditions such as rheumatoid arthritis and multiple sclerosis. Additional crucial applications include population immunosurveillance, either at the general population or at specific communities such as health workers. Finally, we discuss how testing of antibodies in cerebrospinal fluid can inform us on the neurological complications that often accompany COVID-19.
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Affiliation(s)
- Harry Alexopoulos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, Athens, 15784, Greece
| | - Ioannis P Trougakos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, Athens, 15784, Greece
| | - Meletios-Athanasios Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, Alexandra General Hospital, National and Kapodistrian University of Athens, Athens, 11528, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, Alexandra General Hospital, National and Kapodistrian University of Athens, Athens, 11528, Greece.
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17
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Frommert LM, Arumahandi de Silva AN, Zernicke J, Scholz V, Braun T, Jeworowski LM, Schwarz T, Tober-Lau P, ten Hagen A, Habermann E, Kurth F, Sander LE, Corman VM, Burmester GR, Biesen R, Albach FN, Klotsche J. Type of vaccine and immunosuppressive therapy but not diagnosis critically influence antibody response after COVID-19 vaccination in patients with rheumatic disease. RMD Open 2022; 8:rmdopen-2022-002650. [PMID: 36597977 PMCID: PMC9729845 DOI: 10.1136/rmdopen-2022-002650] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/01/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The development of sufficient COVID-19 vaccines has been a big breakthrough in fighting the global SARS-CoV-2 pandemic. However, vaccination effectiveness can be reduced in patients with autoimmune rheumatic diseases (AIRD). The aim of this study was to identify factors that lead to a diminished humoral vaccination response in patients with AIRD. METHODS Vaccination response was measured with a surrogate virus neutralisation test and by testing for antibodies directed against the receptor-binding-domain (RBD) of SARS-CoV-2 in 308 fully vaccinated patients with AIRD. In addition, 296 immunocompetent participants were investigated as a control group. Statistical adjusted analysis included covariates with a possible influence on antibody response. RESULTS Patients with AIRD showed lower antibody responses compared with immunocompetent individuals (median neutralising capacity 90.8% vs 96.5%, p<0.001; median anti-RBD-IgG 5.6 S/CO vs 6.7 S/CO, p<0.001). Lower antibody response was significantly influenced by type of immunosuppressive therapy, but not by rheumatic diagnosis, with patients under rituximab therapy developing the lowest antibody levels. Patients receiving mycophenolate, methotrexate or janus kinase inhibitors also showed reduced vaccination responses. Additional negative influencing factors were vaccination with AZD1222, old age and shorter intervals between the first two vaccinations. CONCLUSION Certain immunosuppressive therapies are associated with lower antibody responses after vaccination. Additional factors such as vaccine type, age and vaccination interval should be taken into account. We recommend antibody testing in at-risk patients with AIRD and emphasise the importance of booster vaccinations in these patients.
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Affiliation(s)
- Leonie Maria Frommert
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Amanthi Nadira Arumahandi de Silva
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Jan Zernicke
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Veronika Scholz
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Tanja Braun
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Lara Maria Jeworowski
- Institute of Virology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany,German Centre for Infection Research (DZIF), Associated Partner Site, Berlin, Germany
| | - Tatjana Schwarz
- Institute of Virology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany,German Centre for Infection Research (DZIF), Associated Partner Site, Berlin, Germany
| | - Pinkus Tober-Lau
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Alexander ten Hagen
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Elisa Habermann
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Florian Kurth
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Leif Erik Sander
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Victor Max Corman
- Institute of Virology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany,German Centre for Infection Research (DZIF), Associated Partner Site, Berlin, Germany,Labor Berlin, Charité - Vivantes GmbH, Berlin, Germany
| | - Gerd-Rüdiger Burmester
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Robert Biesen
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fredrik N. Albach
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Jens Klotsche
- Epidemiology Unit, German Rheumatism Research Center Berlin – a Leibniz Institute (DRFZ), Berlin, Germany
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18
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Glucocorticoid use as a cause of non-cellular immune response to SARS-Cov2 Spike in patients with immune system diseases. J Autoimmun 2022; 133:102912. [PMID: 36115213 PMCID: PMC9464584 DOI: 10.1016/j.jaut.2022.102912] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 12/13/2022]
Abstract
Disease modifying therapies compromise immune response to SARS-Cov2 or its vaccine in patients with immune system diseases (ISD). Therefore, analysis of the humoral and cellular responses against Spike is of utmost importance to manage ISD patients. A single-center retrospective study was conducted to evaluate the impact of COVID-19 immunization in 87 ISD patients and 81 healthy controls. We performed a whole blood interferon gamma release assay using SARS-Cov2 Spike and Nucleocapsid recombinant proteins in order to evaluate T-cell memory response, and an IgG anti-Spike ELISA to evaluate humoral response. Cellular (26.4%) and humoral (44.8%) responses were negative against Spike in ISD patients following COVID-19 immunization. In univariate analysis, an anti-Spike T cell defective response was associated with the use of glucocorticoids (Odds ratio [OR] = 10.0; p < 10-4), serum albumin level ≤40 g/L (OR = 18.9; p < 10-4), age over 55 years old (OR = 3.9, p = 0.009) and ≤2 vaccine injections (OR = 4.9; p = 0.001). The impact of glucocorticoids persisted after adjustment for age and number of vaccine injections (OR = 8.38, p < 0.001). In contrast, the humoral response was impacted by the use of anti-CD20 mAb (OR = 24.8, p < 10-4), and an extended time since immunization (≥75 days; OR = 4.3, p = 0.002). Double defective cellular/humoral responses (6.9%) were typically encountered in glucocorticoids and/or anti-CD20 mAb treated ISD with a serum albumin level ≤40 g/L (OR = 17.5; p = 0.002). Glucocorticoid usage, B cell depleting therapies, and a low serum albumin level were the main factors associated with a non-response to COVID-19 immunization in ISD patients. These results need further confirmation in larger studies.
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19
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Long COVID and the Neuroendocrinology of Microbial Translocation Outside the GI Tract: Some Treatment Strategies. ENDOCRINES 2022. [DOI: 10.3390/endocrines3040058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Similar to previous pandemics, COVID-19 has been succeeded by well-documented post-infectious sequelae, including chronic fatigue, cough, shortness of breath, myalgia, and concentration difficulties, which may last 5 to 12 weeks or longer after the acute phase of illness. Both the psychological stress of SARS-CoV-2 infection and being diagnosed with COVID-19 can upregulate cortisol, a stress hormone that disrupts the efferocytosis effectors, macrophages, and natural killer cells, leading to the excessive accumulation of senescent cells and disruption of biological barriers. This has been well-established in cancer patients who often experience unrelenting fatigue as well as gut and blood–brain barrier dysfunction upon treatment with senescence-inducing radiation or chemotherapy. In our previous research from 2020 and 2021, we linked COVID-19 to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) via angiotensin II upregulation, premature endothelial senescence, intestinal barrier dysfunction, and microbial translocation from the gastrointestinal tract into the systemic circulation. In 2021 and 2022, these hypotheses were validated and SARS-CoV-2-induced cellular senescence as well as microbial translocation were documented in both acute SARS-CoV-2 infection, long COVID, and ME/CFS, connecting intestinal barrier dysfunction to disabling fatigue and specific infectious events. The purpose of this narrative review is to summarize what is currently known about host immune responses to translocated gut microbes and how these responses relate to fatiguing illnesses, including long COVID. To accomplish this goal, we examine the role of intestinal and blood–brain barriers in long COVID and other illnesses typified by chronic fatigue, with a special emphasis on commensal microbes functioning as viral reservoirs. Furthermore, we discuss the role of SARS-CoV-2/Mycoplasma coinfection in dysfunctional efferocytosis, emphasizing some potential novel treatment strategies, including the use of senotherapeutic drugs, HMGB1 inhibitors, Toll-like receptor 4 (TLR4) blockers, and membrane lipid replacement.
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20
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Cardelli C, Caruso T, Tani C, Pratesi F, Talarico R, Di Cianni F, Italiano N, Laurino E, Moretti M, Cascarano G, Diomedi M, Gualtieri L, D'Urzo R, Migliorini P, Mosca M. COVID-19 mRNA vaccine booster in patients with autoimmune rheumatic diseases. Rheumatology (Oxford) 2022; 61:e328-e330. [PMID: 35608304 PMCID: PMC9384146 DOI: 10.1093/rheumatology/keac296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Chiara Cardelli
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
| | - Teresita Caruso
- Department of Clinical and Experimental Medicine, University of Pisa
- Immunoallergology Unit, Azienda Ospedaliero-Universitaria Pisana
| | | | - Federico Pratesi
- Department of Clinical and Experimental Medicine, University of Pisa
- Department of Translational Research and NTMS, University of Pisa, Pisa, Italy
| | | | - Federica Di Cianni
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
| | - Nazzareno Italiano
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
| | - Elenia Laurino
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
| | - Michele Moretti
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
| | - Giancarlo Cascarano
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
| | - Michele Diomedi
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
| | - Luca Gualtieri
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
| | | | - Paola Migliorini
- Department of Clinical and Experimental Medicine, University of Pisa
- Immunoallergology Unit, Azienda Ospedaliero-Universitaria Pisana
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, University of Pisa
- Rheumatology Unit
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21
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Schmiedeberg K, Abela IA, Pikor NB, Vuilleumier N, Schwarzmueller M, Epp S, Pagano S, Grabherr S, Patterson AB, Nussberger M, Trkola A, Ludewig B, von Kempis J, Rubbert-Roth A. Postvaccination anti-S IgG levels predict anti-SARS-CoV-2 neutralising activity over 24 weeks in patients with RA. RMD Open 2022; 8:rmdopen-2022-002575. [PMID: 36288822 PMCID: PMC9615173 DOI: 10.1136/rmdopen-2022-002575] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/30/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To correlate immune responses following a two-dose regimen of mRNA anti-SARS-CoV-2 vaccines in patients with rheumatoid arthritis (RA) to the development of a potent neutralising antiviral activity. METHODS The RECOVER study was a prospective, monocentric study including patients with RA and healthy controls (HCs). Assessments were performed before, and 3, 6, 12 and 24 weeks, after the first vaccine dose, respectively, and included IgG, IgA and IgM responses (against receptor binding domain, S1, S2, N), IFN-γ ELISpots as well as neutralisation assays. RESULTS In patients with RA, IgG responses developed slower with lower peak titres compared with HC. Potent neutralising activity assessed by a SARS-CoV-2 pseudovirus neutralisation assay after 12 weeks was observed in all 21 HCs, and in 60.3% of 73 patients with RA. A significant correlation between peak anti-S IgG levels 2 weeks after the second vaccine dose and potent neutralising activity against SARS-CoV-2 was observed at weeks 12 and 24. The analysis of IgG, IgA and IgM isotype responses to different viral proteins demonstrated a delay in IgG but not in IgA and IgM responses. T cell responses were comparable in HC and patients with RA but declined earlier in patients with RA. CONCLUSION In patients with RA, vaccine-induced IgG antibody levels were diminished, while IgA and IgM responses persisted, indicating a delayed isotype switch. Anti-S IgG levels 2 weeks after the second vaccine dose correlate with the development of a potent neutralising activity after 12 and 24 weeks and may allow to identify patients who might benefit from additional vaccine doses or prophylactic regimen.
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Affiliation(s)
- Kristin Schmiedeberg
- Division of Rheumatology and Immunology, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | - Irene A Abela
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, Zurich, Switzerland
| | | | | | - Magdalena Schwarzmueller
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, Zurich, Switzerland
| | - Selina Epp
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, Zurich, Switzerland
| | - Sabrina Pagano
- Laboratory Medicine Division, University of Geneva, Geneve, Switzerland
| | - Sarah Grabherr
- Institute of Immunobiology, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | | | - Madalina Nussberger
- Division of Rheumatology and Immunology, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | - Alexandra Trkola
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, Zurich, Switzerland
| | - Burkhard Ludewig
- Institute of Immunobiology, Kantonsspital St Gallen, Sankt Gallen, Switzerland,Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Johannes von Kempis
- Division of Rheumatology and Immunology, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | - Andrea Rubbert-Roth
- Division of Rheumatology and Immunology, Kantonsspital St Gallen, Sankt Gallen, Switzerland
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22
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Stahl D, tho Pesch C, Brück C, Esser RL, Thiele J, Di Cristanziano V, Kofler DM. Reduced humoral response to a third dose (booster) of SARS-CoV-2 mRNA vaccines by concomitant methotrexate therapy in elderly patients with rheumatoid arthritis. RMD Open 2022; 8:rmdopen-2022-002632. [PMID: 36216409 PMCID: PMC9556739 DOI: 10.1136/rmdopen-2022-002632] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 11/07/2022] Open
Abstract
Background Several health authorities recommend a third (booster) vaccination to protect patients with rheumatic and musculoskeletal diseases from severe COVID-19. Methotrexate has been shown to reduce the efficacy of the first and second dose of SARS-CoV-2 mRNA vaccines. So far, it remains unknown how concomitant methotrexate affects the efficacy of a COVID-19 booster vaccination. Methods We compared the humoral immune response to SARS-CoV-2 vaccination in 136 patients with rheumatoid arthritis (RA) treated with methotrexate and/or biological or targeted synthetic (b/tsDMARDs). IgG targeting the receptor binding domain (RBD) of SARS-CoV-2 spike protein was measured at a median of 52.5 (range 2–147) days after a third dose of the SARS-CoV-2 mRNA vaccines BNT162b2 or mRNA-1273. Results Anti-RBD IgG was significantly reduced in elderly patients receiving concomitant treatment with methotrexate as compared with elderly patients receiving monotherapy with b/tsDMARDs or methotrexate (64.8 (20.8, 600.3) binding antibody units per mL (BAU/mL) vs 1106.0 (526.3, 4965.2) BAU/mL vs 1743.8 (734.5, 6779.6) BAU/mL, median (IQR), p<0.001, Kruskal-Wallis test). In younger patients (< 64.5 years), concomitant methotrexate had no significant impact on the humoral immune response. Conclusions Concomitant methotrexate increases the risk of an insufficient humoral immune response to SARS-CoV-2 vaccination in elderly patients with RA. Pausing methotrexate during the third vaccination period may be considered for this group of patients.
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Affiliation(s)
- David Stahl
- Department I of Internal Medicine, University of Cologne, Koln, Germany,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Carola tho Pesch
- Department I of Internal Medicine, University of Cologne, Koln, Germany
| | - Carolin Brück
- Department I of Internal Medicine, University of Cologne, Koln, Germany
| | - Ruth L Esser
- Department I of Internal Medicine, University of Cologne, Koln, Germany
| | - Jan Thiele
- Department I of Internal Medicine, University of Cologne, Koln, Germany
| | | | - David M Kofler
- Department I of Internal Medicine, University of Cologne, Koln, Germany,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
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23
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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: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [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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24
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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: 14] [Impact Index Per Article: 7.0] [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: 45] [Impact Index Per Article: 22.5] [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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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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