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Baxter RM, Cabrera-Martinez B, Ghosh T, Rester C, Moreno MG, Borko TL, Selva S, Fleischer CL, Haakonsen N, Mayher A, Bowhay E, Evans C, Miller TM, Huey L, McWilliams J, van Bokhoven A, Deane KD, Knight V, Jordan KR, Ghosh D, Klarquist J, Kedl RM, Piquet AL, Hsieh EWY. SARS-CoV-2 Vaccine-Elicited Immunity after B Cell Depletion in Multiple Sclerosis. Immunohorizons 2024; 8:254-268. [PMID: 38483384 PMCID: PMC10985059 DOI: 10.4049/immunohorizons.2300108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/15/2024] [Indexed: 04/04/2024] Open
Abstract
The impact of B cell deficiency on the humoral and cellular responses to SARS-CoV2 mRNA vaccination remains a challenging and significant clinical management question. We evaluated vaccine-elicited serological and cellular responses in 1) healthy individuals who were pre-exposed to SARS-CoV-2 (n = 21), 2) healthy individuals who received a homologous booster (mRNA, n = 19; or Novavax, n = 19), and 3) persons with multiple sclerosis on B cell depletion therapy (MS-αCD20) receiving mRNA homologous boosting (n = 36). Pre-exposure increased humoral and CD4 T cellular responses in immunocompetent individuals. Novavax homologous boosting induced a significantly more robust serological response than mRNA boosting. MS-α CD20 had an intact IgA mucosal response and an enhanced CD8 T cell response to mRNA boosting compared with immunocompetent individuals. This enhanced cellular response was characterized by the expansion of only effector, not memory, T cells. The enhancement of CD8 T cells in the setting of B cell depletion suggests a regulatory mechanism between B and CD8 T cell vaccine responses.
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Affiliation(s)
- Ryan M. Baxter
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO
| | | | - Tusharkanti Ghosh
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Cody Rester
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO
| | - Miguel Guerrero Moreno
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO
| | - Tyler L. Borko
- Department of Neurology, Sections of Neuroimmunology, Neuroinfectious Disease, and Neurohospitalist, University of Colorado School of Medicine, Aurora, CO
| | - Sean Selva
- Department of Neurology, Sections of Neuroimmunology, Neuroinfectious Disease, and Neurohospitalist, University of Colorado School of Medicine, Aurora, CO
| | - Chelsie L. Fleischer
- Department of Medicine, Division of Rheumatology, University of Colorado, School of Medicine, Aurora, CO
| | - Nicola Haakonsen
- Department of Medicine, Division of Infectious Diseases, University of Colorado, School of Medicine, Aurora, CO
| | - Ariana Mayher
- Allergy and Immunology Research, Research Institute, Children’s Hospital Colorado, Aurora, CO
| | - Emily Bowhay
- Allergy and Immunology Research, Research Institute, Children’s Hospital Colorado, Aurora, CO
| | - Courtney Evans
- Allergy and Immunology Research, Research Institute, Children’s Hospital Colorado, Aurora, CO
| | - Todd M. Miller
- Analytics Resource Center, Children’s Hospital Colorado, Aurora, CO
| | - Leah Huey
- Department of Pediatrics, Section of Allergy and Immunology, University of Colorado, School of Medicine, Aurora, CO
| | - Jennifer McWilliams
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO
| | - Adrie van Bokhoven
- Department of Pathology, Section of Pathology Shared Resource, University of Colorado, Aurora, CO
| | - Kevin D. Deane
- Department of Medicine, Division of Rheumatology, University of Colorado, School of Medicine, Aurora, CO
| | - Vijaya Knight
- Department of Pediatrics, Section of Allergy and Immunology, University of Colorado, School of Medicine, Aurora, CO
| | - Kimberly R. Jordan
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO
| | - Debashis Ghosh
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Jared Klarquist
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO
| | - Ross M. Kedl
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO
| | - Amanda L. Piquet
- Department of Neurology, Sections of Neuroimmunology, Neuroinfectious Disease, and Neurohospitalist, University of Colorado School of Medicine, Aurora, CO
| | - Elena W. Y. Hsieh
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO
- Department of Pediatrics, Section of Allergy and Immunology, University of Colorado, School of Medicine, Aurora, CO
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Britto J, Holbrook A, Sun H, Cserti-Gazdewich C, Prokopchuk-Gauk O, Hsia C, Khamisa K, Yenson PR, Sholzberg M, Olney HJ, Shivakumar S, Jones D, Merkeley H, Costello J, Jamula E, Arnold DM. Thrombopoietin Receptor Agonists and Other Second-Line Therapies for Immune Thrombocytopenia: A Narrative Review With a Focus on Drug Access in Canada. CLIN INVEST MED 2024; 47:13-22. [PMID: 38546381 DOI: 10.3138/cim-2024-2569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is an autoimmune disease characterized by low platelet counts and increased risk of bleeding. After corticosteroids with or without intravenous immune globulin (first-line treatment), second-line treatment options include rituximab, splenectomy, thrombopoietin receptor agonists (TPO-RAs), and fostamatinib. In Canada, the choice of second-line therapy is influenced by access to medications. The goals of this narrative review are to 1) summarize the evidence for the use of TPO-RAs and other second-line therapies in ITP and 2) highlight differences in public funding criteria for TPO-RAs across provinces and territories in Canada. METHODS We conducted a literature review of second-line therapies for ITP. We solicited information on public funding programs for TPO-RAs in Canada from health care providers, pharmacists, and provincial ministries of health. RESULTS Head-to-head trials involving TPO-RAs, rituximab, splenectomy, and fostamatinib are lacking. There is substantial evidence of effect for TPO-RAs in improving platelet count levels, health-related quality of life, bleeding, and fatigue from placebo-controlled trials and observational studies; however, access to TPO-RAs through provincial funding programs in Canada is variable. Splenectomy failure is a prerequisite for the funding of TPO-RAs in Ontario, Manitoba, and Saskatchewan, but not in Alberta or Quebec. Other provinces either do not have access to public funding or funding is provided on a case-by-case basis. DISCUSSION TPO-RAs are effective second-line therapies for the treatment of ITP; however, access is variable across Canada, which results in health disparities and poor uptake of international treatment guidelines.
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Affiliation(s)
- Joanne Britto
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anne Holbrook
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Ontario, Canada
| | - Haowei Sun
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Christine Cserti-Gazdewich
- Department of Medicine/Division of Hematology, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Oksana Prokopchuk-Gauk
- Department of Pathology and Lab Medicine, University of Saskatchewan, Saskatchewan Health Authority, Canada
| | - Cyrus Hsia
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Karima Khamisa
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Paul R Yenson
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michelle Sholzberg
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Harold J Olney
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Sudeep Shivakumar
- Division of Hematology, Nova Scotia Health Authority, Halifax, NS, Canada
| | - David Jones
- Department of Hematology, Eastern Health, Memorial University, Newfoundland & Labrador, Canada
| | - Hayley Merkeley
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jacqueline Costello
- Department of Hematology, Eastern Health, Memorial University, Newfoundland & Labrador, Canada
| | - Erin Jamula
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
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Narbutt J, Żuber Z, Lesiak A, Bień N, Szepietowski JC. Vaccinations in Selected Immune-Related Diseases Treated with Biological Drugs and JAK Inhibitors-Literature Review and Statement of Experts from Polish Dermatological Society. Vaccines (Basel) 2024; 12:82. [PMID: 38250895 PMCID: PMC10820194 DOI: 10.3390/vaccines12010082] [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: 12/19/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
The growing use of biological drugs in immune-mediated chronic diseases has undoubtedly revolutionized their treatment. Yet, the topic of vaccinations in this group of patients still raises many concerns and implies many therapeutic problems that require discussion and standardization of management. The aim of this literature review is to present current knowledge regarding safety and efficacy of vaccinations in dermatological and rheumatological patients treated with biological drugs and JAK inhibitors. Additionally, this article provides recommendation from experts of the Polish Dermatological Society about proper use of vaccinations during therapy with biologics. Generally, all live attenuated vaccines are contraindicated during immunosuppressive/immunomodulatory therapy. If there is need, they should be administered long enough prior to the therapy or after cessation. Yet, inactivated vaccines mostly can be safely used, but the problem in this case is the effectiveness of the vaccination. Most studies report that the immune response in patients on biologics after administration of different inactivated vaccines is similar to or even better than in the control group. Thus, the importance of vaccination among patients on biologics must be emphasized to reduce omissions and the fear of possible side effects or insufficient post-vaccination response.
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Affiliation(s)
- Joanna Narbutt
- Department of Dermatology, Pediatric Dermatology and Oncology Clinic, Medical University of Lodz, 90-419 Lodz, Poland; (J.N.); (A.L.)
| | - Zbigniew Żuber
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland;
| | - Aleksandra Lesiak
- Department of Dermatology, Pediatric Dermatology and Oncology Clinic, Medical University of Lodz, 90-419 Lodz, Poland; (J.N.); (A.L.)
| | - Natalia Bień
- Department of Dermatology, Pediatric Dermatology and Oncology Clinic, Medical University of Lodz, 90-419 Lodz, Poland; (J.N.); (A.L.)
| | - Jacek C. Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland;
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Crassini K, Gibson J. Pathogenesis and management of immune dysfunction secondary to B cell haematological malignancies. Intern Med J 2024; 54:16-25. [PMID: 38066723 DOI: 10.1111/imj.16279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 10/15/2023] [Indexed: 01/26/2024]
Abstract
Malignancies of the B-lymphocyte lineage are among the most diagnosed haematological malignancies in clinical practice. In our community, multiple myeloma (MM) and its precursor condition monoclonal gammopathy of undetermined significance are the commonest, accounting for ~12% of diagnoses, followed by chronic lymphocytic leukaemia (CLL) and its precursor condition monoclonal B lymphocytosis, ~9%. Along with diffuse large B cell lymphoma, follicular lymphoma and marginal zone lymphoma, these conditions comprise around a third of all haematological malignancies diagnosed. Infection remains an important cause of mortality and morbidity in the management of patients with these conditions. This is in part treatment-related but also reflective of disease-related immune dysfunction. Infectious complications account for up to 50% of early mortality in patients with myeloma and up to 50% of all mortality in patients with CLL. A variety of strategies are available to decrease the morbidity and mortality of infectious complications; however, practices vary between countries and often between treating physicians. Treatment options have evolved significantly over the last decade, with the introduction of monoclonal antibodies, small molecule inhibitors, second- and third-generation immunomodulatory agents and CAR-T cell therapy. Much of the data that inform clinical practice in infection management predates current therapeutic approaches. This is in part because of the rapid development of new therapies but also reflective of the long natural history of many of these diseases and the need for prolonged periods of observation. In this article, we review the aspects of disease and treatment that contribute to immune dysfunction in MM, CLL and B-cell non-Hodgkin lymphoma and review the current strategies used to manage immune dysfunction and infection.
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Affiliation(s)
- Kyle Crassini
- MNCCI, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - John Gibson
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Iwabuchi R, Harada M, Yamada A, Aomura D, Yamada Y, Sonoda K, Nakazawa H, Sakai K, Mizukami E, Hashimoto K, Kamijo Y. Anti-SARS-CoV-2 IgG antibody titer after BNT162b2 mRNA COVID-19 vaccination in Japanese patients who underwent renal replacement therapy, hemodialysis, peritoneal dialysis, and kidney transplantation. Clin Exp Nephrol 2023; 27:660-671. [PMID: 37095343 PMCID: PMC10124692 DOI: 10.1007/s10157-023-02348-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/05/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Coronavirus disease (COVID-19) vaccination is recommended for patients undergoing renal replacement therapy (RRT), including hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KT). However, the difference in the immune response between RRT patients and healthy individuals after mRNA vaccines remains uncertain. METHODS This retrospective observational study evaluated the anti-severe-acute-respiratory-syndrome-coronavirus-2 (anti-SARS-CoV-2) IgG antibody acquisition, titers and their changes, normal response rate (reaching titers of healthy individuals), factors associated with a normal response, and effectiveness of booster vaccination in Japanese RRT patients. RESULTS Most HD and PD patients acquired anti-SARS-CoV-2 IgG antibodies after the second vaccination; however, their antibody titers and normal response rates (62-75%) were low compared with those of healthy subjects. Approximately 62% of KT recipients acquired antibodies, but the normal response rate was low (23%). Anti-SARS-CoV-2 IgG antibody waning occurred in the control, HD, and PD groups, while negative or very low titers remained in KT recipients. Third booster vaccination was effective in most HD and PD patients. However, the effect was mild in KT recipients - only 58% reached a normal response level. Multivariate logistic regression analyses demonstrated that younger age, higher serum albumin level, and RRT other than KT were significantly associated with a normal response after the second vaccination. CONCLUSIONS RRT patients, particularly KT recipients, exhibited poor vaccine responses. Booster vaccination would be beneficial for HD and PD patients; however, its effect in KT recipients was mild. Further COVID-19 vaccinations using the latest vaccine or alternative procedures should be considered in RRT patients.
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Affiliation(s)
- Ryohei Iwabuchi
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
- Kashiwabara Clinic, 4565-1 Hotaka Kashiwabara, Azumino, 399-8304, Japan
| | - Makoto Harada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
- Kashiwabara Clinic, 4565-1 Hotaka Kashiwabara, Azumino, 399-8304, Japan
| | - Aiko Yamada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
- Kashiwabara Clinic, 4565-1 Hotaka Kashiwabara, Azumino, 399-8304, Japan
| | - Daiki Aomura
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Kosuke Sonoda
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Hideyuki Nakazawa
- Department of Hematology and Oncology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Kaoko Sakai
- Department of Hematology and Oncology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Etsuko Mizukami
- Kashiwabara Clinic, 4565-1 Hotaka Kashiwabara, Azumino, 399-8304, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yuji Kamijo
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
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Alexander S, Aupérin A, Bomken S, Csóka M, Kazanowska B, Chiang AK, Andres M, Uyttebroeck A, Burke GAA, Zsiros J, Pillon M, Bollard CM, Mussolin L, Verdu-Amoros J, Neven B, Barkauskas DA, Wheatley K, Patte C, Gross TG, Minard-Colin V. Effect of rituximab on immune status in children with mature B-cell non-Hodgkin lymphoma: a prespecified secondary analysis of the Inter-B-NHL Ritux 2010 trial. Lancet Haematol 2023; 10:e445-e457. [PMID: 37094596 PMCID: PMC10350968 DOI: 10.1016/s2352-3026(23)00062-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Survival of children and adolescents with high-risk, mature B-cell non-Hodgkin lymphoma is improved by the addition of rituximab to chemotherapy. The effect of rituximab on immune reconstitution after therapy has not been well described. Herein, we evaluate the immune effects of the addition of rituximab to intensive chemotherapy, a prespecified secondary aim of the Inter-B-NHL Ritux 2010 trial. METHODS The Inter-B-NHL Ritux 2010 trial was an international, open-label, randomised, phase 3 trial in children (age 6 months to 18 years) with high-risk, mature B-cell non-Hodgkin lymphoma, comparing chemotherapy alone or chemotherapy with rituximab. Measures of immune status were completed at baseline, 1 month from the end of treatment, and 1 year from the start of therapy, and yearly thereafter until normalised. For this secondary analysis, we report on the proportions of patients with low lymphocyte counts and immunoglobulin concentrations at these timepoints with total lymphocyte count, B-cell count, and IgG concentration as the main endpoints. Other endpoints of interest included exposure to immunoglobulin replacement therapy and vaccine serologies. The population assessed for immune endpoints was the eligible per-protocol population with at least one immune parameter at one timepoint. Comparisons of immune status were made between the randomised treatment groups. Safety in the post-therapy period was assessed in the population eligible for the immunity study who were followed up at least 3 months after the end of treatment and without cancer-related events. The Inter-B-NHL Ritux 2010 study was registered with ClinicalTrials.gov, NCT01516580; status completed, with analyses of secondary aims ongoing. FINDINGS From Dec 19, 2011, to June 13, 2017, 421 patients (344 [82%] boys and 77 [18%] girls; mean age was 8·8 years [SD 4·1]) were enrolled and had immune data at baseline during follow-up, or both. The study population included randomly assigned patients (n=289) and a non-randomised cohort enrolled after the planned interim analysis (n=132). At baseline, 99 (34%) of 290 patients with available data (excluding patients with bone marrow disease with peripheral blast cells) had lymphopenia, and 178 (48%) of 368 had hypogammaglobulinemia. 1 month from the end of therapy, patients who received chemotherapy with rituximab were more likely than those who received chemotherapy alone to have lymphopenia (86 [81%] of 106 vs 53 (60%) of 89, odds ratio [OR] 2·92 [95% CI 1·53-5·57], p=0·0011), B-cell lymphopenia (72 [96%] of 75 vs 36 [64%] of 56, OR 13·33 [3·71-47·84], p<0·0001), and hypogammaglobulinemia (67 [71%] of 95 vs 37 [47%] of 79, OR 2·72 [1·45-5·07], p=0·0017). Differences remained at 1 year for hypogammaglobulinemia only (52 [55%] of 94 vs 16 [25%] of 63, OR 3·64 [1·81-7·31], p=0·0003). Patients in the chemotherapy with rituximab group were more likely than those in the chemotherapy group to receive immunoglobulin replacement (26 [16%] 164 vs nine [7%] of 158, hazard ratio [HR] 2·63 [95% CI 1·23-5·62], p=0·010), mainly due to low immunoglobulin concentration. In the combined treatment groups, including non-randomly assigned patients, the proportion of patients who had loss of protective serologies to a vaccine preventable infection varied from four (9%) of 47 for polio to 21 (42%) of 50 for Streptococcus pneumoniae (pneumococcus). One patient (chemotherapy with rituximab group) had a life-threatening infectious event of polymicrobial bacterial sepsis reported 2 months after the final chemotherapy administration. INTERPRETATION Children with high-risk mature B-cell non-Hodgkin lymphoma receiving chemotherapy with rituximab were at risk of prolonged hypogammaglobulinemia, although severe infections were rare. Strategies for immunoglobulin replacement and revaccination are needed. FUNDING Clinical Research Hospital Program of the French Ministry of Health, Cancer Research UK, National Institute for Health Research Clinical Research Network in England, Children's Cancer Foundation Hong Kong, US National Cancer Institute, F Hoffmann-La Roche.
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Affiliation(s)
- Sarah Alexander
- Division of Pediatric Haematology/Oncology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
| | - Anne Aupérin
- Biostatistics and Epidemiology Office, Gustave Roussy, INSERM U1018 Oncostat, Labelled Ligue Contre le Cancer, Université Paris-Saclay, Villejuif, France
| | - Simon Bomken
- Wolfson Childhood Cancer Research Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; The Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Monika Csóka
- Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Bernarda Kazanowska
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Alan K Chiang
- Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Mara Andres
- Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain
| | - Anne Uyttebroeck
- Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium
| | - G A Amos Burke
- Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - József Zsiros
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Marta Pillon
- Maternal and Child Health Department, Padova University, Padova, Italy
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children's National Hospital and The George Washington University, Washington, DC, USA
| | - Lara Mussolin
- Maternal and Child Health Department, Padova University, Padova, Italy; Unit of Oncohematology, Stem Cell Transplant and Gene Therapy, Istituto di Ricerca Pediatrica Città della Speranza, Padova, Italy
| | - Jaime Verdu-Amoros
- Department of Pediatric Hematology and Oncology, University Hospital Valencia, Valencia, Spain
| | - Bénédicte Neven
- Department of Pediatric Immunology, Hematology and Rheumatology, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Unit of Pediatric Immunology, Haematology and Rheumatology, Paris Cité University, Imagine Institute, Paris, France
| | - Donald A Barkauskas
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, California, LA, USA
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Catherine Patte
- Departments of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Thomas G Gross
- Center for Cancer and Blood Disorders, Children's Hospital of Colorado, Aurora, CO, USA
| | - Véronique Minard-Colin
- Departments of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France; INSERM U1015, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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Yamasaki S. Bisphosphonate use for glucocorticoid-induced osteoporosis in older patients with immune thrombocytopenia: a clinical perspective. Ann Hematol 2023:10.1007/s00277-023-05266-7. [PMID: 37171596 PMCID: PMC10175903 DOI: 10.1007/s00277-023-05266-7] [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: 01/04/2023] [Accepted: 05/06/2023] [Indexed: 05/13/2023]
Abstract
Prednisolone, used as a standard initial treatment for immune thrombocytopenia (ITP), is an important risk factor for osteoporosis. Recently, we found that prescription of bisphosphonate during initial loading of prednisolone may prevent reduction in bone mineral density and development of glucocorticoid-induced osteoporosis (GIO) in older patients with ITP receiving prolonged steroid therapy. In this review, I describe the treatment options for older patients with ITP, and present the best practices for screening, evaluating, and diagnosing ITP. I also summarize the literature from 2017 to 2022 on the treatment options for ITP, including discussions on the contraindications and side effects, with an emphasis on GIO, and the relative merits of bisphosphonates as a co-treatment for prevention of GIO. Finally, I present a perspective and an expert recommendation on how older patients with ITP would best be served in the future.
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Affiliation(s)
- Satoshi Yamasaki
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Oita, 874-0838, Japan.
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, 810-0065, Japan.
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Rivière E, Thiébaut R, Lazaro E, Guy A, James C, Mansier O, Blanco P, Viallard JF. Assessment of circulating blood lymphocytes in adult patients on rituximab to treat immune thrombocytopenia: Circulating number of NK cells is associated with the response at 6 months. Br J Haematol 2023. [PMID: 37081607 DOI: 10.1111/bjh.18818] [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: 11/30/2022] [Revised: 03/19/2023] [Accepted: 04/09/2023] [Indexed: 04/22/2023]
Abstract
Immune thrombocytopenia (ITP) is defined by a low platelet count that can trigger potentially life-threatening haemorrhages. Three-quarters of adult patients exhibit persistent or chronic disease and require second-line treatments. Among these, rituximab, an anti-CD20 antibody, has yielded valuable results, with global responses in 60% of patients at 6 months and complete responses in 30% at 5 years. Factors predictive of response to ITP therapy would help physicians choose optimal treatments. We retrospectively analysed clinical courses, biological markers and blood lymphocyte subset numbers of 72 patients on rituximab to treat persistent/chronic ITP followed-up in our department between 2007 and 2021, divided into three groups according to the platelet count at 6 months: complete, partial or no response. Among all studied parameters, a low number of CD3- CD16+ CD56+ circulating NK cells was associated with the complete response to rituximab. We also found that, after rituximab therapy, complete responders exhibited increased NK and decreased activated CD8+ T cell percentages. These results emphasize that the role played by NK cells in ITP remains incompletely known but that factors predictive of response to rituximab can be easily derived using blood lymphocyte subset data.
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Affiliation(s)
- Etienne Rivière
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- INSERM U1034, Bordeaux University, Pessac Cedex, France
| | - Rodolphe Thiébaut
- Department of Public Health, University of Bordeaux, INSERM U1219 Bordeaux Population Health Research Centre, Inria SISTM, UMR 1219, Bordeaux, France
- Department of Medical Information, University Hospital Centre of Bordeaux, Bordeaux, France
| | - Estibaliz Lazaro
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- UMR CNRS 5164, ImmunoconcEpT & FHU ACRONIM, Bordeaux University, Bordeaux, France
| | - Alexandre Guy
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Chloé James
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Olivier Mansier
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Patrick Blanco
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- UMR CNRS 5164, ImmunoconcEpT & FHU ACRONIM, Bordeaux University, Bordeaux, France
| | - Jean-François Viallard
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- INSERM U1034, Bordeaux University, Pessac Cedex, France
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9
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Wang L, Wang Y, Cheng X, Li X, Li J. Impact of coronavirus disease 2019 on lung cancer patients: A meta-analysis. Transl Oncol 2023; 28:101605. [PMID: 36568513 PMCID: PMC9760620 DOI: 10.1016/j.tranon.2022.101605] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic poses a great challenge to the treatment of lung cancer patients. Materials and methods The PubMed, Embase, and Web of Science databases were searched for studies published before March 15, 2022, and Stata 14.0 software was used to perform a meta-analysis with a random-effects model. The odds ratio (OR) along with the corresponding 95% confidence interval (CI) was reported. Results Our meta-analysis included 80 articles with 318,352 patients involved. The proportion of lung cancer patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was 2.4% (95% CI: 0.02-0.03) prior to the Omicron variant outbreak. Among COVID-19 patients, those with lung cancer showed a higher mortality rate than those with other types of malignant solid tumors (OR = 1.82, 95% CI: 1.61-2.06) and non-cancer patients (OR = 4.67, 95% CI: 3.61-6.05); however, no significant difference was observed in the mortality rate between patients with lung cancer and those with hematologic malignancies (OR = 1.07, 95% CI: 0.85-1.33). SARS-CoV-2 infection significantly increased the mortality rate in lung cancer patients (OR = 8.94, 95% CI: 6.50-12.31). By contrast, the all-cause mortality rate in lung cancer patients (OR = 1.04, 95% CI: 0.69-1.57) and the proportion of patients diagnosed with advanced lung cancer (OR = 1.04, 95% CI: 0.85-1.27) did not significantly change before and after the pandemic. Conclusions More attention should be paid on improving the health of lung cancer patients during the COVID-19 pandemic.
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Affiliation(s)
- Linlin Wang
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China
| | - Ye Wang
- Department of Pediatrics, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China
| | - Xianbin Cheng
- Department of Gastrointestinal Colorectal and Anal Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China
| | - Xingzhao Li
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China
| | - Jun Li
- Department of Hematology and Oncology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China.
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10
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Anat GG. Current approaches for the diagnosis and management of immune thrombocytopenia. Eur J Intern Med 2023; 108:18-24. [PMID: 36424271 DOI: 10.1016/j.ejim.2022.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/05/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Immune thrombocytopenia (ITP), is an acquired autoimmune disorder characterized by the destruction of platelets and megakaryocytes, resulting in thrombocytopenia (platelet count <100 × 10⁹/L). This review focuses on the diagnosis and current management of ITP. The diagnosis of ITP is based principally on the exclusion of other causes of isolated thrombocytopenia using patient history, physical examination, blood count, and evaluation of the peripheral blood film. The clinical treatment goals should be to resolve bleeding events and to prevent severe bleeding episodes. The platelet count should be improved to attain a minimum of > 20-30 × 10⁹/L. Therapy should be given as an inpatient in newly diagnosed ITP with a platelet count of > 20 × 10⁹/L or if there is active bleeding. Corticosteroids are considered the standard initial treatment for newly diagnosed patients. Subsequent medical therapies with robust evidence include thrombopoietin receptor agonists (TPO-RAs), rituximab and fostamatinib. Surgical therapy with splenectomy may be considered for patients failing medical therapy. The choice between therapy options is highly dependent upon patient values and preferences.
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Affiliation(s)
- Gafter-Gvili Anat
- Department of Medicine A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
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11
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Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
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Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
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12
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Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Williams EA, Mikuls TR. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 5. Arthritis Rheumatol 2023; 75:E1-E16. [PMID: 36345691 PMCID: PMC9878068 DOI: 10.1002/art.42372] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/02/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the use of COVID-19 vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious diseases specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS Despite a paucity of direct evidence, statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines, including supplemental/booster dosing, in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION These guidance statements are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.
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Affiliation(s)
| | - Sindhu R. Johnson
- Toronto Western HospitalMount Sinai Hospital, and University of TorontoTorontoOntarioCanada
| | - Donald D. Anthony
- Louis Stokes Cleveland VA Medical CenterMetroHealth Medical Center, and Case Western Reserve UniversityClevelandOhio
| | - Reuben J. Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical CenterDallas
| | | | - Anne R. Bass
- Hospital for Special Surgery and Weill Cornell MedicineNew YorkNew York
| | | | | | | | | | | | | | | | - Ted R. Mikuls
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care SystemOmaha
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13
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Van Meerhaeghe T, Néel A, Brouard S, Degauque N. Regulation of CD8 T cell by B-cells: A narrative review. Front Immunol 2023; 14:1125605. [PMID: 36969196 PMCID: PMC10030846 DOI: 10.3389/fimmu.2023.1125605] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
Activation of CD4 T cells by B cells has been extensively studied, but B cell-regulated priming, proliferation, and survival of CD8 T cells remains controversial. B cells express high levels of MHC class I molecules and can potentially act as antigen-presenting cells (APCs) for CD8 T cells. Several in vivo studies in mice and humans demonstrate the role of B cells as modulators of CD8 T cell function in the context of viral infections, autoimmune diseases, cancer and allograft rejection. In addition, B-cell depletion therapies can lead to impaired CD8 T-cell responses. In this review, we attempt to answer 2 important questions: 1. the role of B cell antigen presentation and cytokine production in the regulation of CD8 T cell survival and cell fate determination, and 2. The role of B cells in the formation and maintenance of CD8 T cell memory.
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Affiliation(s)
- Tess Van Meerhaeghe
- Department of Nephrology, Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
| | - Antoine Néel
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
- Internal Medicine Department, Nantes University Hospital, Nantes, France
| | - Sophie Brouard
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
| | - Nicolas Degauque
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, Nantes, France
- *Correspondence: Nicolas Degauque,
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14
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Khawaja F, Papanicolaou G, Dadwal S, Pergam SA, Wingard JR, Boghdadly ZE, Abidi MZ, Waghmare A, Shahid Z, Michaels L, Hill JA, Kamboj M, Boeckh M, Auletta JJ, Chemaly RF. Frequently Asked Questions on Coronavirus Disease 2019 Vaccination for Hematopoietic Cell Transplantation and Chimeric Antigen Receptor T-Cell Recipients From the American Society for Transplantation and Cellular Therapy and the American Society of Hematology. Transplant Cell Ther 2023; 29:10-18. [PMID: 36273782 PMCID: PMC9584756 DOI: 10.1016/j.jtct.2022.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), disproportionately affects immunocompromised and elderly patients. Not only are hematopoietic cell transplantation (HCT) and chimeric antigen receptor (CAR) T-cell recipients at greater risk for severe COVID-19 and COVID-19-related complications, but they also may experience suboptimal immune responses to currently available COVID-19 vaccines. Optimizing the use, timing, and number of doses of the COVID-19 vaccines in these patients may provide better protection against SARS-CoV-2 infection and better outcomes after infection. To this end, current guidelines for COVID-19 vaccination in HCT and CAR T-cell recipients from the American Society of Transplantation and Cellular Therapy Transplant Infectious Disease Special Interest Group and the American Society of Hematology are provided in a frequently asked questions format.
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Affiliation(s)
- Fareed Khawaja
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Genovefa Papanicolaou
- Division of Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sanjeet Dadwal
- Division of Infectious Diseases, City of Hope, Duarte, California
| | - Steven A Pergam
- Vaccine and Infectious Diseases, Fred Hutchinson Cancer Center, Seattle, Washington
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
| | - Zeinab El Boghdadly
- Division of Infectious Diseases, The Ohio State University College of Medicine, Columbus, Ohio
| | - Maheen Z Abidi
- Division of Infectious Diseases, University of Colorado, Boulder, Colorado
| | - Alpana Waghmare
- Division of Infectious Diseases, Seattle Children's Hospital, Seattle, Washington
| | - Zainab Shahid
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Laura Michaels
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joshua A Hill
- Vaccine and Infectious Diseases, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Mini Kamboj
- Division of Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Boeckh
- Vaccine and Infectious Diseases, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Jeffery J Auletta
- National Marrow Donor Program/Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota; Divisions of Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
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15
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Uaprasert N, Pitakkitnukun P, Tangcheewinsirikul N, Chiasakul T, Rojnuckarin P. Immunogenicity and risks associated with impaired immune responses following SARS-CoV-2 vaccination and booster in hematologic malignancy patients: an updated meta-analysis. Blood Cancer J 2022; 12:173. [PMID: 36550105 PMCID: PMC9780106 DOI: 10.1038/s41408-022-00776-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Patients with hematologic malignancies (HM) have demonstrated impaired immune responses following SARS-CoV-2 vaccination. Factors associated with poor immunogenicity remain largely undetermined. A literature search was conducted using PubMed, EMBASE, Cochrane, and medRxiv databases to identify studies that reported humoral or cellular immune responses (CIR) following complete SARS-CoV-2 vaccination. The primary aim was to estimate the seroconversion rate (SR) following complete SARS-CoV-2 vaccination across various subtypes of HM diseases and treatments. The secondary aims were to determine the rates of development of neutralizing antibodies (NAb) and CIR following complete vaccination and SR following booster doses. A total of 170 studies were included for qualitative and quantitative analysis of primary and secondary outcomes. A meta-analysis of 150 studies including 20,922 HM patients revealed a pooled SR following SARS-CoV-2 vaccination of 67.7% (95% confidence interval [CI], 64.8-70.4%; I2 = 94%). Meta-regression analysis showed that patients with lymphoid malignancies, but not myeloid malignancies, had lower seroconversion rates than those with solid cancers (R2 = 0.52, P < 0.0001). Patients receiving chimeric antigen receptor T-cells (CART), B-cell targeted therapies or JAK inhibitors were associated with poor seroconversion (R2 = 0.39, P < 0.0001). The pooled NAb and CIR rates were 52.8% (95% CI; 45.8-59.7%, I2 = 87%) and 66.6% (95% CI, 57.1-74.9%; I2 = 86%), respectively. Approximately 20.9% (95% CI, 11.4-35.1%, I2 = 90%) of HM patients failed to elicit humoral and cellular immunity. Among non-seroconverted patients after primary vaccination, only 40.5% (95% CI, 33.0-48.4%; I2 = 87%) mounted seroconversion after the booster. In conclusion, HM patients, especially those with lymphoid malignancies and/or receiving CART, B-cell targeted therapies, or JAK inhibitors, showed poor SR after SARS-CoV-2 vaccination. A minority of patients attained seroconversion after booster vaccination. Strategies to improve immune response in these severely immunosuppressed patients are needed.
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Affiliation(s)
- Noppacharn Uaprasert
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
| | - Palada Pitakkitnukun
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nuanrat Tangcheewinsirikul
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Thita Chiasakul
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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16
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Recommendations on the Management of Patients with Immune Thrombocytopenia (ITP) in the Context of SARS-CoV-2 Infection and Vaccination: Consensus Guidelines from a Spanish ITP Expert Group. Infect Dis Ther 2022; 12:303-315. [PMID: 36520323 PMCID: PMC9753022 DOI: 10.1007/s40121-022-00745-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Primary immune thrombocytopenia (ITP) is an acquired autoimmune disease with highly variable presentation, characteristics, and clinical course. Thrombocytopenia is a common complication of many viral infections, including SARS-CoV-2. In addition, both de novo ITP and exacerbation of ITP after vaccination against SARS-CoV-2 have been reported. Patients infected with SARS-CoV-2 develop a prothrombotic coagulopathy called COVID-19-associated coagulopathy (CAC). In addition, autoimmune hematological disorders secondary to SARS-CoV-2 infection, mainly ITP and autoimmune hemolytic anemia (AIHA), have been described. Furthermore, SARS-CoV-2 infection has been associated with exacerbation of autoimmune processes, including ITP. In fact, there is evidence of a high relapse rate in patients with preexisting ITP and COVID-19. As for vaccination against SARS-CoV-2, hematological adverse events (HAE) are practically anecdotal. The most common HAE is thrombocytopenia-associated thrombosis syndrome (TTS) linked to vectored virus vaccines. Other HAEs are very rare, but should be considered in patients with previous complement activation disease or autoimmunity. In patients with ITP who are vaccinated against SARS-CoV-2, the main complication is exacerbation of ITP and the bleeding that may result. In fact, this complication occurs in 12% of patients, with splenectomized and refractory patients with more than five lines of previous treatment and platelet counts below 50 × 109/L being the most vulnerable. We conclude that, in general, there is no greater risk of severe SARS-CoV-2 infection in ITP patients than in the general population. Furthermore, no changes are advised in patients with stable ITP, the use of immunosuppressants is discouraged unless there is no other therapeutic option, and patients with ITP are not contraindicated for vaccination against COVID-19.
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17
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Sakai A, Morishita T, Suzumura K, Hanatate F, Yoshikawa T, Sasaki N, Lee S, Fujita K, Hara T, Araki H, Tagami A, Murayama M, Yamada R, Iwata A, Sobajima T, Kasahara Y, Matsuzawa Y, Takemura M, Yamamoto Y, Fujigaki H, Saito K, Tsurumi H, Matsunami H. The Trajectory of the COVID-19 Vaccine Antibody Titers Over Time and the Association of Mycophenolate Mofetil in Solid Organ Transplant Recipients. Transplant Proc 2022; 54:2638-2645. [PMID: 36372567 PMCID: PMC9537258 DOI: 10.1016/j.transproceed.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/03/2022] [Accepted: 10/03/2022] [Indexed: 01/07/2023]
Abstract
The COVID-19 vaccine will be safe and effective in solid organ transplant recipients (SOTs). However, the blunted antibody responses were also of concern. Few studies have reported prolonged serologic follow-up after 2 doses of BNT162b2 vaccine in SOTs. We performed a single-center, prospective observational study of 78 SOTs who received 2 doses of BNT162b2 vaccine. We identified the trajectory of antibody titers after vaccination among SOTs with or without mycophenolate mofetil (MMF) or withdrawn from MMF. We found low seroconversion rates (29/42: 69%) and low antibody titers in SOTs treated with MMF. An inverse linear relationship between neutralizing antibody titers and MMF concentration was confirmed in restricted cubic spline plots (P for effect < .01, P for nonlinearity = .08). For the trajectory of antibody responses, seroconversion and improved antibody titers were observed after withdrawal from MMF in SOTs who showed seronegative or low antibody titers at the first visit after 2 doses of vaccine (P for effect < .01, P for nonlinearity < .05, and P for interaction < .01). We identified increased B-cell counts after withdrawal from MMF (P < .01). The recovery of antibody responses was seen in SOTs withdrawn from MMF. The trajectories of antibody responses were modified by MMF administration.
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Affiliation(s)
- Akiyoshi Sakai
- Department of Clinical Laboratory, Matsunami General Hospital, Gifu, Japan
| | - Tetsuji Morishita
- Department of Internal Medicine, Matsunami General Hospital, Gifu, Japan,Matsunami Research Park, Gifu, Japan,Address correspondence to Tetsuji Morishita, Vice Director of Internal Medicine, Matsunami General Hospital, 185-1 Dendai, Kasamatsu-cho, Hashima-gun, Gifu 501-6062, Japan
| | - Kaori Suzumura
- Department of Clinical Laboratory, Matsunami General Hospital, Gifu, Japan
| | - Fumika Hanatate
- Department of Breast Surgery, Matsunami General Hospital, Gifu, Japan
| | | | | | - Shin Lee
- Department of Hematology, Matsunami General Hospital, Gifu, Japan
| | - Kei Fujita
- Department of Hematology, Matsunami General Hospital, Gifu, Japan
| | - Takeshi Hara
- Department of Hematology, Matsunami General Hospital, Gifu, Japan
| | - Hiroshi Araki
- Department of Gastroenterology, Matsunami General Hospital, Gifu, Japan
| | - Atsushi Tagami
- Department of Gastroenterology, Matsunami General Hospital, Gifu, Japan
| | - Masanori Murayama
- Department of Internal Medicine, Matsunami General Hospital, Gifu, Japan
| | - Rie Yamada
- Department of Internal Medicine, Matsunami General Hospital, Gifu, Japan
| | - Akira Iwata
- Department of Internal Medicine, Matsunami General Hospital, Gifu, Japan
| | - Takuya Sobajima
- Department of Internal Medicine, Matsunami General Hospital, Gifu, Japan
| | - Yukiko Kasahara
- Department of Pediatrics, Matsunami General Hospital, Gifu, Japan
| | - Yoriko Matsuzawa
- Department of Pediatrics, Matsunami General Hospital, Gifu, Japan
| | - Masao Takemura
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Sciences, Toyoake, Aichi, Japan
| | - Yasuko Yamamoto
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Sciences, Toyoake, Aichi, Japan
| | - Hidetsugu Fujigaki
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Sciences, Toyoake, Aichi, Japan
| | - Kuniaki Saito
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Sciences, Toyoake, Aichi, Japan
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Wang X, Sima L. Antibody response after vaccination against SARS-CoV-2 in adults with hematological malignancies: a systematic review and meta-analysis. J Infect 2022:S0163-4453(22)00674-0. [PMID: 36417984 PMCID: PMC9675635 DOI: 10.1016/j.jinf.2022.11.013] [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: 10/23/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
Vaccines against SARS-CoV-2 have shown remarkable efficacy and thus constitute an important preventive option against coronavirus disease 2019 (COVID-19), especially in fragile patients. We aimed to systematically analyze the outcomes of patients with hematological malignancies who received vaccination and to identify specific groups with differences in outcomes. The primary end point was antibody response after full vaccination (2 doses of mRNA or one dose of vector- based vaccines). We identified 49 studies comprising 11,086 individuals. Overall risk of bias was low. The pooled response for hematological malignancies was 64% (95% confidence interval [CI]: 59-69; I²=93%) versus 96% (95% CI: 92-97; I²=44%) for solid cancer and 98% (95% CI: 96-99; I²=55%) for healthy controls (P<0.001). Outcome was different across hematological malignancies (P<0.001). The pooled response was 50% (95% CI: 43-57; I²=84%) for chronic lymphocytic leukemia, 76% (95% CI: 67-83; I²=92%) for multiple myeloma, 83% (95% CI: 69-91; I²=85%) for myeloproliferative neoplasms, 91% (95% CI: 82-96; I²=12%) for Hodgkin lymphoma, and 58% (95% CI: 44-70; I²=84%) for aggressive and 61% (95% CI: 48-72; I²=85%) for indolent non-Hodgkin lymphoma. The pooled response for allogeneic and autologous hematopoietic cell transplantation was 82% and 83%, respectively. Being in remission and prior COVID-19 showed significantly higher responses. Low pooled response was identified for active treatment (35%), anti-CD20 therapy ≤1 year (15%), Bruton kinase inhibition (23%), venetoclax (26%), ruxolitinib (42%), and chimeric antigen receptor T-cell therapy (42%). Studies on timing, value of boosters, and long-term efficacy are needed. This study is registered with PROSPERO (clinicaltrials gov. Identifier: CRD42021279051).
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - Laozei Sima
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
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Vishnevetsky A, Kaplan TB, Levy M. Transitioning immunotherapy in neuromyelitis optica spectrum disorder – when and how to switch. Expert Opin Biol Ther 2022; 22:1393-1404. [DOI: 10.1080/14712598.2022.2145879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Anastasia Vishnevetsky
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tamara B. Kaplan
- Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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20
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Jiang D, Al-Samkari H, Panch SR. Changing Paradigms in ITP Management: Newer Tools for an Old Disease. Transfus Med Rev 2022; 36:188-194. [PMID: 36273934 PMCID: PMC10044485 DOI: 10.1016/j.tmrv.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by isolated thrombocytopenia that may be accompanied clinically by bleeding and reduced health-related quality of life (HRQoL). While corticosteroids, splenectomy, and various immunosuppressants (used off-label) have served as historical mainstays of ITP treatment, their use is associated with adverse effects and morbidity. Over the last 15 years, the advent of the thrombopoietin receptor agonists has revolutionized the management of chronic ITP with high response rates, durable responses, and minimal adverse effects in most patients. With four agents now FDA-approved to manage chronic ITP, there is a renewed emphasis on improving HRQoL and minimizing the toxicities associated with traditional therapies. Promising agents with diverse mechanisms of action, ranging from those targeting Bruton's Tyrosine Kinase to the neonatal Fc receptor, are currently under investigation. This review highlights recent landmark clinical trials which have made significant impacts on ITP management and ongoing drug development. In critically analyzing studies of relevance, we illustrate the changing paradigms of ITP management and how the field is advancing beyond traditional therapies.
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Affiliation(s)
- Debbie Jiang
- Division of Hematology, University of Washington, Seattle, WA, USA
| | - Hanny Al-Samkari
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA; Division of Hematology, Harvard Medical School, Boston, MA, USA
| | - Sandhya R Panch
- Division of Hematology, University of Washington, Seattle, WA, USA; Transfusion Services, Seattle Cancer Care Alliance, Seattle, WA, USA.
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21
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Wang S, Perlmutter JW, Johnston J, Nugent Z, Wiseman M. Rituximab Treatment of Primary Cutaneous Follicle Center Lymphoma: A Retrospective Review. J Cutan Med Surg 2022; 26:604-612. [PMID: 36134749 DOI: 10.1177/12034754221126119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary cutaneous B-cell lymphoma (PCBCL) presents only in the skin at the time of diagnosis with no evidence of extracutaneous disease, and primary cutaneous follicle center lymphoma (PCFCL) is the most common subtype. There is currently a lack of prospective randomized control trials and large retrospective studies investigating the efficacy of different treatment options for PCFCL. This retrospective study was conducted to describe our local clinical experience and outcomes of patients treated with rituximab-containing regimens. OBJECTIVES To describe our local clinical experience and treatment outcomes of patients treated with rituximab-containing regimens. METHODS A retrospective study consisting of 25 PCFCL patients treated with different modalities. Patient records were reviewed and analyzed using a Kaplan-Meier estimation and SAS 9.4 software. RESULTS After the initial treatment, all patients had CR except for 1 patient in the observation group. Further, 60% of patients in surgery, 20% in chemoimmunotherapy, 67% in rituximab monotherapy, 33% in steroid injection/systemic prednisone, and 33% in observation experienced a relapse. Although no significant difference was found between treatment groups due to the small sample size, time to relapse trends provides insight into treatment responses. Chemoimmunotherapy had the lowest relapse rate in the first 5 years post-treatment, whereas surgery had a higher tendency to relapse. CONCLUSIONS Despite the potential for rituximab-containing chemoimmunotherapy to yield adverse effects, it is effective in achieving a prolonged clinical remission in patients with PCFCL. It remains a reasonable treatment option for diffuse, extensive, or treatment-resistant disease.
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Affiliation(s)
- Siru Wang
- 12359 University of Manitoba, Max Rady College of Medicine, Winnipeg, MB, Canada
| | - Jonah W Perlmutter
- 8665 Department of Biochemistry, University of Winnipeg, Winnipeg, MB, Canada
| | - James Johnston
- 8647 Department of Hematology and Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Zoann Nugent
- 8647 Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Marni Wiseman
- 8664 Section of Dermatology, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.,SKiNWISE DERMATOLOGY, Winnipeg, Manitoba, Canada
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22
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Abdolkarimi B, Amanati A, Molavi Vardanjani H, Jamshidi S, Tabaeian SAP. Antibody waning after immunosuppressive chemotherapy and immunomodulators, re-immunization considerations in pediatric patients with malignancy and chronic immune thrombocytopenic purpura. BMC Infect Dis 2022; 22:657. [PMID: 35902837 PMCID: PMC9335959 DOI: 10.1186/s12879-022-07647-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/25/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Immunosuppressive chemotherapy increase the risk of vaccine-preventable infectious diseases in children; nevertheless, chemotherapy may result in delay or miss updated immunization schedules. The predictable antibody waning after incomplete primary immunization series may be intensified at the end of chemotherapy. This study aimed to investigate post-chemotherapy vaccine immunity waning at the end of immunosuppressive therapy in children with malignancy and hematologic disorders. Materials and methods Children with malignancies and hematologic disorders including chronic immune thrombocytopenic purpura (ITP) younger than 18 years old were enrolled from September 2015 to August 2019. Eligible patients who completed their treatment protocol for at least 6 months were recruited. The patient information, including sex, age at the date of diagnosis, number of chemotherapy sessions, underlying disease, and vaccination history, was taken by chart review using predefined questionnaires. The patient’s blood samples were obtained, and serum IgG antibody titer checked against diphtheria, tetanus, hepatitis B virus (HBV), mumps, measles, and rubella (MMR) were measured by enzyme-linked immunosorbent assay (ELISA). Results 110 children receiving immunosuppressive chemotherapy were recruited. Forty-four (40%) of the children tested were girls and 66 (60%) were boys. The mean age of patients was 5.5 years with a range of 2 to 13 years. Of 110 studied children, 27.3% were seronegative for all antibodies. On average, patients undergo 19 episodes of chemotherapy. The mean chemotherapy sessions were significantly greater in children who were seronegative for all tested antibodies (mean: 36.2, 95% CI 33.16 to 39.24, p-value < 0.001). No statistically significant differences were observed regarding the patient’s sex and age between the seropositive and seronegative groups (p-value 0.513 and 0.060, respectively). Based on Poisson regression model analysis, the female gender was associated with 37% lower odds of seronegativity (incidence rate ratio (IIR): 0.63; [95% conf. interval: 0.39 to 1.01, p-value: 0.55]), while chemotherapy sessions 30 or more was associated with significant odds of seronegativity for all tested vaccines (IIR: 25.41; [95% conf. interval: 6.42 to 100.57, p-value < 0.001]). Conclusion Our results reemphasized planned catchup immunization in children undergoing immunosuppressive chemotherapy for malignancy, especially against tetanus, diphtheria, and hepatitis B at least 6 months after the end of chemotherapy sessions.
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Affiliation(s)
| | - Ali Amanati
- Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Hossein Molavi Vardanjani
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
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23
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Martire B, Ottaviano G, Sangerardi M, Sgrulletti M, Chini L, Dellepiane RM, Montin D, Rizzo C, Pignata C, Marseglia GL, Moschese V. Vaccinations in Children and Adolescents Treated With Immune-Modifying Biologics: Update and Current Developments. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1485-1496. [PMID: 35085809 DOI: 10.1016/j.jaip.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 06/14/2023]
Abstract
Treatment with immune-modifying biologics has positively impacted disease control and quality of life in many patients with immune-mediated disorders. However, the higher susceptibility to common and opportunistic pathogens is of concern. Thus, immunization strategies to control vaccine-preventable diseases represent a critical issue in this population. However, limited data exist on the safety, immunogenicity, and efficacy of available vaccines in patients on biologics, particularly in children. Here, according to published literature and real-life experience and practice, we report the interim indications of the Italian Society of Pediatric Allergology and Immunology (SIAIP) Vaccine Committee and of the Italian Primary Immunodeficiency Network (IPINet) Centers on immunization of children and adolescents receiving biologics. Our aim is to provide a practical guidance for the clinician to ensure optimal protection for patients and the community.
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Affiliation(s)
- Baldassarre Martire
- Pediatrics and Neonatology Unit, Maternal-Infant Department, Monsignor A. R. Dimiccoli Hospital, Barletta, Italy.
| | - Giorgio Ottaviano
- Molecular and Cellular Immunology Unit, Great Ormond Street Institute of Child Health, University College of London, London, UK
| | - Maria Sangerardi
- Department of Pediatrics and Emergency, Pediatric Hospital, Policlinico - University of Bari, Bari, Italy
| | - Mayla Sgrulletti
- Pediatric Immunopathology and Allergology Unit, University of Rome, Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - Loredana Chini
- Pediatric Immunopathology and Allergology Unit, University of Rome, Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - Rosa Maria Dellepiane
- Pediatric Intermediate Care Unit, Scientific Institute for Research, Hospitalization and Healthcare Foundation (IRCSS); Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Montin
- Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Caterina Rizzo
- Innovation and Clinical Pathways Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences-Section of Pediatrics, Federico II University of Naples, Naples, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, IRCCS Foundation, Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, University of Rome, Tor Vergata, Policlinico Tor Vergata, Rome, Italy
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24
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Fujii T, Hagihara M, Mitamura K, Nakashima S, Ohara S, Uchida T, Inoue M, Okuda M, Yasuhara A, Murakami J, Duong C, Iwatsuki-Horimoto K, Yamayoshi S, Kawaoka Y. Anti-SARS CoV-2 IgG in COVID-19 Patients with Hematological Diseases: A Single-center, Retrospective Study in Japan. Intern Med 2022; 61:1681-1686. [PMID: 35342138 PMCID: PMC9259303 DOI: 10.2169/internalmedicine.9209-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread globally. Although the relationship between anti-SARS-CoV-2 immunoglobulin G (IgG) antibodies and COVID-19 severity has been reported, information is lacking regarding the seropositivity of patients with particular types of diseases, including hematological diseases. Methods In this single-center, retrospective study, we compared SARS-CoV-2 IgG positivity between patients with hematological diseases and those with non-hematological diseases. Results In total, 77 adult COVID-19 patients were enrolled. Of these, 30 had hematological disorders, and 47 had non-hematological disorders. The IgG antibody against the receptor-binding domain of the spike protein was detected less frequently in patients with hematological diseases (60.0%) than in those with non-hematological diseases (91.5%; p=0.029). Rituximab use was significantly associated with seronegativity (p=0.010). Conclusion Patients with hematological diseases are less likely to develop anti-SARS-CoV-2 antibodies than those with non-hematological diseases, which may explain the poor outcomes of COVID-19 patients in this high-risk group.
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Affiliation(s)
- Takayuki Fujii
- Department of Hematology, Eiju General Hospital, Japan
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Japan
| | | | - Keiko Mitamura
- Division of Infection Control, Eiju General Hospital, Japan
| | | | - Shin Ohara
- Department of Hematology, Eiju General Hospital, Japan
| | | | | | - Moe Okuda
- Division of Virology, Institute of Medical Science, University of Tokyo, Japan
| | - Atsuhiro Yasuhara
- Division of Virology, Institute of Medical Science, University of Tokyo, Japan
| | - Jurika Murakami
- Division of Virology, Institute of Medical Science, University of Tokyo, Japan
| | - Calvin Duong
- Division of Virology, Institute of Medical Science, University of Tokyo, Japan
| | | | - Seiya Yamayoshi
- Division of Virology, Institute of Medical Science, University of Tokyo, Japan
- The Research Center for Global Viral Diseases, Research Institute, National Center for Global Health and Medicine, Japan
| | - Yoshihiro Kawaoka
- Division of Virology, Institute of Medical Science, University of Tokyo, Japan
- The Research Center for Global Viral Diseases, Research Institute, National Center for Global Health and Medicine, Japan
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25
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Stefanski A, Rincon‐Arevalo H, Schrezenmeier E, Karberg K, Szelinski F, Ritter J, Jahrsdörfer B, Schrezenmeier H, Ludwig C, Sattler A, Kotsch K, Chen Y, Claußnitzer A, Haibel H, Proft F, Guerra G, Durek P, Heinrich F, Ferreira‐Gomes M, Burmester GR, Radbruch A, Mashreghi M, Lino AC, Dörner T. B Cell Numbers Predict Humoral and Cellular Response Upon SARS-CoV-2 Vaccination Among Patients Treated With Rituximab. Arthritis Rheumatol 2022; 74:934-947. [PMID: 34962360 PMCID: PMC9011692 DOI: 10.1002/art.42060] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/25/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with autoimmune inflammatory rheumatic diseases receiving rituximab (RTX) therapy are at higher risk of poor COVID-19 outcomes and show substantially impaired humoral immune response to anti-SARS-CoV-2 vaccine. However, the complex relationship between antigen-specific B cells and T cells and the level of B cell repopulation necessary to achieve anti-vaccine responses remain largely unknown. METHODS Antibody responses to SARS-CoV-2 vaccines and induction of antigen-specific B and CD4/CD8 T cell subsets were studied in 19 patients with rheumatoid arthritis (RA) or antineutrophil cytoplasmic antibody-associated vasculitis receiving RTX, 12 patients with RA receiving other therapies, and 30 healthy controls after SARS-CoV-2 vaccination with either messenger RNA or vector-based vaccines. RESULTS A minimum of 10 B cells per microliter (0.4% of lymphocytes) in the peripheral circulation appeared to be required for RTX-treated patients to mount seroconversion to anti-S1 IgG upon SARS-CoV-2 vaccination. RTX-treated patients who lacked IgG seroconversion showed reduced receptor-binding domain-positive B cells (P = 0.0005), a lower frequency of Tfh-like cells (P = 0.0481), as well as fewer activated CD4 (P = 0.0036) and CD8 T cells (P = 0.0308) compared to RTX-treated patients who achieved IgG seroconversion. Functionally relevant B cell depletion resulted in impaired interferon-γ secretion by spike-specific CD4 T cells (P = 0.0112, r = 0.5342). In contrast, antigen-specific CD8 T cells were reduced in both RA patients and RTX-treated patients, independently of IgG formation. CONCLUSION In RTX-treated patients, a minimum of 10 B cells per microliter in the peripheral circulation is a candidate biomarker for a high likelihood of an appropriate cellular and humoral response after SARS-CoV-2 vaccination. Mechanistically, the data emphasize the crucial role of costimulatory B cell functions for the proper induction of CD4 responses propagating vaccine-specific B cell and plasma cell differentiation.
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Affiliation(s)
- Ana‐Luisa Stefanski
- Charité Universitätsmedizin Berlin and Deutsches RheumaforschungszentrumBerlinGermany
| | - Hector Rincon‐Arevalo
- Charité Universitätsmedizin Berlin and Deutsches Rheumaforschungszentrum, Berlin, Germany, and Universidad de AntioquiaMedellínColombia
| | - Eva Schrezenmeier
- Charité Universitätsmedizin, Berlin, Deutsches Rheumaforschungszentrum Berlin and Berlin Institute of Health BIH AcademyBerlinGermany
| | | | - Franziska Szelinski
- Charité Universitätsmedizin Berlin and Deutsches RheumaforschungszentrumBerlinGermany
| | - Jacob Ritter
- Charité Universitätsmedizin Berlin and Berlin Institute of Health BIH AcademyBerlinGermany
| | - Bernd Jahrsdörfer
- Ulm University, Ulm, Germany, Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden‐Württemberg–Hessen, and University Hospital UlmUlmGermany
| | - Hubert Schrezenmeier
- Ulm University, Ulm, Germany, Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden‐Württemberg–Hessen, and University Hospital UlmUlmGermany
| | - Carolin Ludwig
- Ulm University, Ulm, Germany, Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden‐Württemberg–Hessen, and University Hospital UlmUlmGermany
| | | | | | - Yidan Chen
- Charité Universitätsmedizin Berlin and Deutsches RheumaforschungszentrumBerlinGermany
| | | | | | | | | | - Pawel Durek
- Deutsches RheumaforschungszentrumBerlinGermany
| | | | | | - Gerd R. Burmester
- Charité Universitätsmedizin Berlin and Deutsches RheumaforschungszentrumBerlinGermany
| | | | | | | | - Thomas Dörner
- Charité Universitätsmedizin Berlin and Deutsches RheumaforschungszentrumBerlinGermany
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26
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Bahrs C, Harrison N. Vaccine Response in the Immunocompromised Patient with Focus on Cellular Immunity. Vaccines (Basel) 2022; 10:vaccines10060882. [PMID: 35746489 PMCID: PMC9230619 DOI: 10.3390/vaccines10060882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/24/2022] [Indexed: 12/10/2022] Open
Abstract
During the last few years, we have experienced a shift in how we evaluate the effectiveness of vaccines [...]
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Affiliation(s)
- Christina Bahrs
- Institute for Infectious Diseases and Infection Control, Jena University Hospital—Friedrich Schiller University, 07747 Jena, Germany
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, 1090 Vienna, Austria;
- Correspondence: ; Tel.: +49-(0)-36419-324769; Fax: +49-(0)-36419-324652
| | - Nicole Harrison
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, 1090 Vienna, Austria;
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Abstract
Multiple sclerosis (MS) is a chronic autoimmune demyelinating disease of the central nervous system (CNS) that often progresses to severe disability. Previous studies have highlighted the role of T cells in disease pathophysiology; however, the success of B-cell-targeted therapies has led to an increased interest in how B cells contribute to disease immunopathology. In this review, we summarize evidence of B-cell involvement in MS disease mechanisms, starting with pathology and moving on to review aspects of B cell immunobiology potentially relevant to MS. We describe current theories of critical B cell contributions to the inflammatory CNS milieu in MS, namely (i) production of autoantibodies, (ii) antigen presentation, (iii) production of proinflammatory cytokines (bystander activation), and (iv) EBV involvement. In the second part of the review, we summarize medications that have targeted B cells in patients with MS and their current position in the therapeutic armamentarium based on clinical trials and real-world data. Covered therapeutic strategies include the targeting of surface molecules such as CD20 (rituximab, ocrelizumab, ofatumumab, ublituximab) and CD19 (inebilizumab), and molecules necessary for B-cell activation such as B cell activating factor (BAFF) (belimumab) and Bruton's Tyrosine Kinase (BTK) (evobrutinib). We finally discuss the use of B-cell-targeted therapeutics in pregnancy.
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Tolf A, Wiberg A, Müller M, Nazir FH, Pavlovic I, Laurén I, Mangsbo S, Burman J. Factors Associated With Serological Response to SARS-CoV-2 Vaccination in Patients With Multiple Sclerosis Treated With Rituximab. JAMA Netw Open 2022; 5:e2211497. [PMID: 35544139 PMCID: PMC9096596 DOI: 10.1001/jamanetworkopen.2022.11497] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/24/2022] [Indexed: 12/14/2022] Open
Abstract
Importance B-cell-depleting monoclonal antibodies are widely used for treatment of multiple sclerosis but are associated with an impaired response to vaccines. Objective To identify factors associated with a favorable vaccine response to tozinameran. Design, Setting, and Participants This prospective cohort study was conducted in a specialized multiple sclerosis clinic at a university hospital from January 21 to December 1, 2021. Of 75 patients evaluated for participation who received a diagnosis of multiple sclerosis with planned or ongoing treatment with rituximab, 69 were included in the study, and data from 67 were analyzed. Exposures Sex, age, number of previous rituximab infusions, accumulated dose of rituximab, previous COVID-19 infection, time since last rituximab treatment, CD19+ B-cell count before vaccination, CD4+ T-cell count, and CD8+ T-cell count were considered potential factors associated with the main outcome. Main Outcomes and Measures Serological vaccine responses were measured by quantitation of anti-spike immunoglobulin G (IgG) antibodies, anti-receptor-binding domain (RBD) IgG antibodies, and their neutralizing capacities. Cellular responses to spike protein-derived SARS-CoV-2 peptide pools were assessed by counting interferon gamma spot-forming units in a FluoroSpot assay. Results Among 60 patients with ongoing rituximab treatment (49 women [82%]; mean (SD) age, 43 [10] years), the median (range) disease duration was 9 (1-29) years, and the median (range) dose of rituximab was 2750 (500-10 000) mg during a median (range) time of 2.8 (0.5-8.3) years. The median (range) follow-up from the first vaccination dose was 7.3 (4.3-10.0) months. Vaccine responses were determined before vaccination with tozinameran and 6 weeks after vaccination. By using established cutoff values for anti-spike IgG (264 binding antibody units/mL) and anti-RBD IgG (506 binding antibody units/mL), the proportion of patients with a positive response increased with the number of B cells, which was the only factor associated with these outcomes. A cutoff for the B-cell count of at least 40/μL was associated with an optimal serological response. At this cutoff, 26 of 29 patients (90%) had positive test results for anti-spike IgG and 21 of 29 patients (72%) for anti-RBD IgG, and 27 of 29 patients (93%) developed antibodies with greater than 90% inhibition of angiotensin-converting enzyme 2. No factor associated with the cellular response was identified. Depending on the peptide pool, 21 of 25 patients (84%) to 22 of 25 patients (88%) developed a T-cell response with interferon gamma production at the B-cell count cutoff of at least 40/μL. Conclusions and Relevance This cohort study found that for an optimal vaccine response from tozinameran, rituximab-treated patients with multiple sclerosis may be vaccinated as soon as possible, with rituximab treatment delayed until B-cell counts have reached at least 40/μL. An additional vaccination with tozinameran should be considered at that point.
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Affiliation(s)
- Andreas Tolf
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Anna Wiberg
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Malin Müller
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Ivan Pavlovic
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Ida Laurén
- Department of Pharmacy, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Sara Mangsbo
- Department of Pharmacy, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Williams EA, Mikuls TR. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 4. Arthritis Rheumatol 2022; 74:e21-e36. [PMID: 35474640 PMCID: PMC9082483 DOI: 10.1002/art.42109] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/02/2022] [Accepted: 03/02/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the use of COVID-19 vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS Despite a paucity of direct evidence, statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines, including supplemental/booster dosing, in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION These guidance statements are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.
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Affiliation(s)
| | - Sindhu R. Johnson
- Toronto Western HospitalMount Sinai Hospital, and University of TorontoTorontoOntarioCanada
| | - Donald D. Anthony
- Louis Stokes Cleveland VA Medical CenterMetroHealth Medical Center, and Case Western Reserve UniversityClevelandOhio
| | - Reuben J. Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical CenterDallas
| | | | - Anne R. Bass
- Hospital for Special Surgery and Weill Cornell MedicineNew YorkNew York
| | | | | | | | | | | | | | | | - Ted R. Mikuls
- University of Nebraska Medical Center and VA Nebraska–Western, Iowa Health Care SystemOmaha
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30
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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31
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Kamegai K, Iwamoto N, Togano T, Maeda K, Takamatsu Y, Miyazato Y, Ishikane M, Mizokami M, Sugiyama M, Iida S, Miyamoto S, Suzuki T, Ohmagari N. A Fatal Breakthrough Coronavirus Disease 2019 Case Following Bendamustine-Rituximab Therapy. Int J Infect Dis 2022; 121:85-88. [PMID: 35500795 PMCID: PMC9054701 DOI: 10.1016/j.ijid.2022.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 11/27/2022] Open
Abstract
Although messenger ribonucleic acid vaccines are substantially effective toward SARS-CoV-2 infection, patients with hematologic malignancies are still prone to the virus. Herein, we report a fatal case of breakthrough SARS-CoV-2 Delta variant infection in a patient with mucosa-associated lymphoid tissue lymphoma with remission by bendamustine-rituximab (BR) therapy completed a year ago. The serologic study revealed impaired responsiveness toward vaccines and prolonged high viral load after infection. BR therapy seemingly induced an immune escape. Prevention and treatment strategies for such vulnerable patients should be clarified immediately.
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Affiliation(s)
- Kohei Kamegai
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Noriko Iwamoto
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Tomiteru Togano
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Kenji Maeda
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Yuki Takamatsu
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Yusuke Miyazato
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Masahiro Ishikane
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Masashi Mizokami
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Masaya Sugiyama
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan
| | - Shun Iida
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Sho Miyamoto
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Tadaki Suzuki
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Norio Ohmagari
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Tokyo, Japan.
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BNT162b2 COVID-19 Vaccine Induced Immune Thrombocytopenic Purpura. Case Rep Med 2022; 2022:5603919. [PMID: 35464782 PMCID: PMC9019434 DOI: 10.1155/2022/5603919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/28/2022] [Indexed: 12/18/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) has been reported following vaccinations such as MMR as well as after viral infections such as hepatitis C and HIV. Few case reports have been reported of ITP after COVID-19 infections and COVID-19 vaccines. Herein, we present a patient who presented with severe ITP with a platelet count of 0 after receiving the second dose of the BNT162b2 mRNA COVID-19 vaccine (also known as the Pfizer BioNTech). She subsequently recovered with a prolonged treatment course.
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33
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Bemben NM, Berg ML. Efficacy of inactivated vaccines in patients treated with immunosuppressive drug therapy. Pharmacotherapy 2022; 42:334-342. [PMID: 35146780 PMCID: PMC9088666 DOI: 10.1002/phar.2671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Nina M. Bemben
- Wolters Kluwer Clinical Effectiveness Chicago Illinois USA
| | - Melody L. Berg
- American Society of Health‐System Pharmacists Bethesda Maryland USA
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34
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Kantarcioglu B, Iqbal O, Lewis J, Carter CA, Singh M, Lievano F, Ligocki M, Jeske W, Adiguzel C, Gerotziafas GT, Fareed J. An Update on the Status of Vaccine Development for SARS-CoV-2 Including Variants. Practical Considerations for COVID-19 Special Populations. Clin Appl Thromb Hemost 2022; 28:10760296211056648. [PMID: 35167393 PMCID: PMC8851053 DOI: 10.1177/10760296211056648] [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] [Indexed: 01/09/2023] Open
Abstract
The progress in the development of various vaccine platforms against SARS-CoV-2 have been rather remarkable owing to advancement in molecular and biologic sciences. Most of the current vaccines and those in development focus on targeting the viral spike proteins by generating antibodies of varying spectrum. These vaccines represent a variety of platforms including whole virus vaccines, viral vector vaccines, nucleic acid vaccines representing RNA, DNA, and their hybrid forms.The therapeutic efficacy of these vaccines varies owing to their pharmacodynamic individualities. COVID-19 variants are capable of inducing different pathologic responses and some of which may be resistant to antibodies generated by current vaccines. The current clinical use of these vaccines has been through emergency use authorization until recently. Moreover, the efficacy and safety of these vaccines have been tested in substantial numbers of individuals but studies in special populations that better reflect the global population are pending results. These specialized populations include young children, immunocompromised patients, pregnant individuals, and other specialized groups. Combination approaches, molecularly modified vaccination approaches, and vaccines conferring longer periods of immunity are being currently being investigated, as well as pharmacovigilance studies.The continual transformation of SARS-CoV-2 and its variants are of concern along with the breakthrough infections. These considerations pose new challenges for the development of vaccination platforms. For this purpose, booster doses, combination vaccine approaches, and other modalities are being discussed. This review provides an updated account of currently available vaccines and those in advanced development with reference to their composition and mechanisms of action.A discussion on the use of vaccines in special populations including immunocompromised patients, pregnant women and other specialized populations are also included.
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Affiliation(s)
- Bulent Kantarcioglu
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA,Bulent Kantarcioglu, Department of Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL 60153, USA.
| | - Omer Iqbal
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Joseph Lewis
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Charles A. Carter
- Campbell University College of Pharmacy and Health Sciences, Campbell University, Buies Creek, NC, USA
| | - Meharvan Singh
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | | | | | - Walter Jeske
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | | | - Grigoris T. Gerotziafas
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Thrombosis Center, Service D’Hématologie Biologique Hôpital Tenon, Paris, France
| | - Jawed Fareed
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
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35
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Sakano T, Bittner EA, Chang MG. Severe COVID pneumonia and undetectable B cells after vaccination in patients previously treated with rituximab: a case series. Postgrad Med 2022; 134:239-243. [PMID: 35129061 DOI: 10.1080/00325481.2022.2037359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The risk of developing severe COVID-19 illness despite completing vaccination for patients who have previously received immunosuppressive therapy is unclear. CASE PRESENTATION We present three patients who received rituximab for treatment of autoimmune disorders who subsequently developed severe COVID-19 pneumonia post-vaccination requiring intensive care unit admission and found to have undetectable B cells. DISCUSSION While there have been concerns about the effectiveness of COVID-19 vaccines in this patient cohort, this is the first case series to report development of severe COVID-19 illness after completing vaccination in those who previously received rituximab. Guidelines for the optimal timing of COVID-19 vaccination in relation to immunosuppressive therapy have been recently published, albeit after many patients in this subpopulation have already been vaccinated. CONCLUSION This case series brings attention to the limited humoral response to vaccines in patients treated with rituximab, highlights existing guidelines and their limitations, and raises future considerations about the potential benefits to testing vaccine responsiveness.
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Affiliation(s)
- Takashi Sakano
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Edward A Bittner
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marvin G Chang
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
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36
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Rüthrich MM, Giesen N, Mellinghoff SC, Rieger CT, von Lilienfeld-Toal M. Cellular Immune Response after Vaccination in Patients with Cancer-Review on Past and Present Experiences. Vaccines (Basel) 2022; 10:182. [PMID: 35214642 PMCID: PMC8875094 DOI: 10.3390/vaccines10020182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 01/27/2023] Open
Abstract
Patients with cancer are at particular risk for infection but also have diminished vaccine responses, usually quantified by the level of specific antibodies. Nonetheless, vaccines are specifically recommended in this vulnerable patient group. Here, we discuss the cellular part of the vaccine response in patients with cancer. We summarize the experience with vaccines prior to and during the SARS-CoV-2 pandemic in different subgroups, and we discuss why, especially in patients with cancer, T cells may be the more reliable correlate of protection. Finally, we provide a brief outlook on options to improve the cellular response to vaccines.
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Affiliation(s)
- Maria Madeleine Rüthrich
- Department of Internal Medicine II, Hematology and Medical Oncology, Universitätsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany;
- Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institut, Adolf-Reichwein-Straße 23, 07745 Jena, Germany
| | - Nicola Giesen
- Department of Haematology and Oncology, Internal Medicine V, University Hospital Heidelberg, 69115 Heidelberg, Germany;
| | - Sibylle C. Mellinghoff
- Centre for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, University of Cologne, 50923 Cologne, Germany;
| | - Christina T. Rieger
- Hemato-Oncology Germering & Interdisciplinary Tumorcenter, Ludwig-Maximilians-University Munich, 81377 Munich, Germany;
| | - Marie von Lilienfeld-Toal
- Department of Internal Medicine II, Hematology and Medical Oncology, Universitätsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany;
- Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institut, Adolf-Reichwein-Straße 23, 07745 Jena, Germany
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37
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Chisari CG, Sgarlata E, Arena S, Toscano S, Luca M, Patti F. Rituximab for the treatment of multiple sclerosis: a review. J Neurol 2022; 269:159-183. [PMID: 33416999 PMCID: PMC7790722 DOI: 10.1007/s00415-020-10362-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 01/07/2023]
Abstract
In the last decades, evidence suggesting the direct or indirect involvement of B cells on multiple sclerosis (MS) pathogenesis has accumulated. The increased amount of data on the efficacy and safety of B-cell-depleting therapies from several studies has suggested the addition of these drugs as treatment options to the current armamentarium of disease modifying therapies (DMTs) for MS. Particularly, rituximab (RTX), a chimeric monoclonal antibody directed at CD20 positive B lymphocytes resulting in cell-mediated apoptosis, has been demonstrated to reduce inflammatory activity, incidence of relapses and new brain lesions on magnetic resonance imaging (MRI) in patients with relapsing-remitting MS (RRMS). Additional evidence also demonstrated that patients with progressive MS (PMS) may benefit from RTX, which also showed to be well tolerated, with acceptable safety risks and favorable cost-effectiveness profile.Despite these encouraging results, RTX is currently approved for non-Hodgkin's lymphoma, chronic lymphocytic leukemia, several forms of vasculitis and rheumatoid arthritis, while it can only be administered off-label for MS treatment. Between Northern European countries exist different rules for using not licensed drug for treating MS. The Sweden MS register reports a high rate (53.5%) of off-label RTX prescriptions in relation to other annually started DMTs to treat MS patients, while Danish and Norwegian neurologists have to use other anti-CD20 drugs, as ocrelizumab, in most of the cases.In this paper, we review the pharmacokinetics, pharmacodynamics, clinical efficacy, safety profile and cost effectiveness aspects of RTX for the treatment of MS. Particularly, with the approval of new anti-CD20 DMTs, the recent worldwide COVID-19 emergency and the possible increased risk of infection with this class of drugs, this review sheds light on the use of RTX as an alternative treatment option for MS management, while commenting the gaps of knowledge regarding this drug.
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Affiliation(s)
- Clara Grazia Chisari
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Eleonora Sgarlata
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
- Stroke Unit, Department of Medicine, Umberto I Hospital, Siracusa, Italy
| | - Sebastiano Arena
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Simona Toscano
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Maria Luca
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Francesco Patti
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy.
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Hagihara M, Imai Y, Uchida T, Ohara S, Inoue M, Sugi T, Mitamura K. Successful Elimination of SARS-CoV-2 Following Vaccination with BNT162b2 after Prolonged Viral Infection in an Immunocompromised Lymphoma Patient. Intern Med 2022; 61:2215-2219. [PMID: 35850990 PMCID: PMC9381351 DOI: 10.2169/internalmedicine.9513-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 52-year-old man with mantle cell lymphoma treated with bendamustine and rituximab developed prolonged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Despite elevated titers of anti-spike IgG antibody, protracted pancytopenia persisted for more than six months. Finally, the anti-SARS CoV-2 vaccine, BNT162b2, was administered, which improved his blood cell count and eliminated the virus. The increased anti-spike IgG titer and lymphocyte count after vaccination suggested that both humoral and cellular immunity acted in coordination to eliminate the virus.
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Affiliation(s)
| | - Yui Imai
- Department of Hematology, Eiju General Hospital, Japan
| | | | - Shin Ohara
- Department of Hematology, Eiju General Hospital, Japan
| | | | - Tomiyuki Sugi
- Department of Pharmacy, Eiju General Hospital, Japan
| | - Keiko Mitamura
- Department of Preventive Medicine, Eiju General Hospital, Japan
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Ercoli G, Ramos‐Sevillano E, Pearce E, Ragab S, Goldblatt D, Weckbecker G, Brown JS. Maintained partial protection against Streptococcus pneumoniae despite B-cell depletion in mice vaccinated with a pneumococcal glycoconjugate vaccine. Clin Transl Immunology 2022; 11:e1366. [PMID: 35003749 PMCID: PMC8715227 DOI: 10.1002/cti2.1366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/16/2021] [Accepted: 12/16/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Anti-CD20 monoclonal antibody therapy rapidly depletes > 95% of CD20+ B cells from the circulation. B-cell depletion is an effective treatment for autoimmune disease and B-cell malignancies but also increases the risk of respiratory tract infections. This effect on adaptive immunity could be countered by vaccination. We have used mouse models to investigate the effects of B-cell depletion on pneumococcal vaccination, including protection against infection and timing of vaccination in relation to B-cell depletion. METHODS C57BL/6 female mice were B-cell depleted using anti-CD20 antibody and immunized with two doses of Prevnar-13 vaccine either before or after anti-CD20 treatment. B-cell repertoire and Streptococcus pneumoniae-specific IgG levels were measured using whole-cell ELISA and flow cytometry antibody-binding assay. Protection induced by vaccination was assessed by challenging the mice using a S. pneumoniae pneumonia model. RESULTS Antibody responses to S. pneumoniae were largely preserved in mice B-cell depleted after vaccination resulting in full protection against pneumococcal infections. In contrast, mice vaccinated with Prevnar-13 while B cells were depleted (with > 90% reduction in B-cell numbers) had decreased circulating anti-S. pneumoniae IgG and IgM levels (measured using ELISA and flow cytometry antibody binding assays). However, some antibody responses were maintained, and, although vaccine-induced protection against S. pneumoniae infection was impaired, septicaemia was still prevented in 50% of challenged mice. CONCLUSIONS This study showed that although vaccine efficacy during periods of profound B-cell depletion was impaired some protective efficacy was preserved, suggesting that vaccination remains beneficial.
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Affiliation(s)
- Giuseppe Ercoli
- Centre for Inflammation and Tissue RepairUCL RespiratoryDivision of MedicineUniversity College Medical SchoolRayne InstituteLondonUK
| | - Elisa Ramos‐Sevillano
- Centre for Inflammation and Tissue RepairUCL RespiratoryDivision of MedicineUniversity College Medical SchoolRayne InstituteLondonUK
| | - Emma Pearce
- Department of ImmunobiologyUCL Great Ormond Street Institute of Child HealthNIHR Biomedical Research CentreLondonUK
| | - Sara Ragab
- Department of ImmunobiologyUCL Great Ormond Street Institute of Child HealthNIHR Biomedical Research CentreLondonUK
| | - David Goldblatt
- Department of ImmunobiologyUCL Great Ormond Street Institute of Child HealthNIHR Biomedical Research CentreLondonUK
| | | | - Jeremy S Brown
- Centre for Inflammation and Tissue RepairUCL RespiratoryDivision of MedicineUniversity College Medical SchoolRayne InstituteLondonUK
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40
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Mair MJ, Berger JM, Berghoff AS, Starzer AM, Ortmayr G, Puhr HC, Steindl A, Perkmann T, Haslacher H, Strassl R, Tobudic S, Lamm WW, Raderer M, Mitterer M, Fuereder T, Fong D, Preusser M. Humoral Immune Response in Hematooncological Patients and Health Care Workers Who Received SARS-CoV-2 Vaccinations. JAMA Oncol 2022; 8:106-113. [PMID: 34591965 PMCID: PMC8485209 DOI: 10.1001/jamaoncol.2021.5437] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/24/2021] [Indexed: 12/14/2022]
Abstract
Importance To our knowledge, little is known about antibody development after SARS-CoV-2 vaccination in immunocompromised individuals, such as patients with cancer. Objective To determine whether hematooncological patients develop anti-SARS-CoV-2 antibodies after vaccination. Design, Setting, and Participants This retrospective cohort study included 2 independent cohorts of patients who were treated for hematological and solid malignant tumors between October 2020 and May 2021, comprising 901 samples from 595 patients and 58 health care workers (HCWs). Serum samples were collected from patients who were treated at an academic center and a community hospital in a rural area and a control group of HCWs, all of whom received SARS-CoV-2 vaccination. Main Outcomes and Measures Total anti-SARS-CoV-2 nucleocapsid (anti-NC) and antispike protein (anti-S) antibodies were measured retrospectively. Results In total, 595 patients (320 women [53.8%] and 275 men [46.2%]; median [range] age, 67 [19-96] years) and 58 HCWs (40 women [69.0%] and 18 men [31.0%]; median [range] age, 42 [24-60] years) were included. Previous SARS-CoV-2 infection was documented in 43 of 595 (7.2%), while anti-NC antibodies that suggested previous infections were observed in 49 of 573 evaluable patients (8.6%). In both cohorts, anti-S antibody levels were higher in fully vaccinated patients compared with patients who received 1 dose. After the first vaccination, patients with hematological cancer who received B cell-targeting agents had lower anti-S levels (median, 1.6 AU/mL; range: 0-17 244 AU/mL) than patients who received other therapies (median, 191.6 AU/mL; range, 0-40 000; P < .001) or patients with solid tumors (median, 246.4 AU/mL; range, 0-40 000 AU/mL; P < .001). Anti-S levels after the first vaccination differed according to ongoing antineoplastic treatment modalities, with the lowest median levels in patients who received chemotherapy alone (157.7 AU/mL; range, 0-40 000 AU/mL) or in combination with immunotherapy (118.7 AU/mL; range, 14.1-38 727 AU/mL) and the highest levels in patients with no ongoing antineoplastic treatment (median, 634.3 AU/mL; range, 0-40 000 AU/mL; P = .01). Antibody levels after full immunization were higher in HCWs (median, 2500 U/mL; range, 485-2500 U/mL) than in patients with cancer (median, 117.0 U/mL; range, 0-2500 U/mL; P < .001). Conclusions and Relevance In this cohort study of patients with hematooncological diseases and a control group of HCWs, anti-SARS-CoV-2 antibodies after vaccination could be detected in patients with cancer. Lower antibody levels compared with HCWs and differences in seroconversion in specific subgroups underscore the need for further studies on SARS-CoV-2 vaccination in patients with hematooncological disease.
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Affiliation(s)
- Maximilian J. Mair
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Julia M. Berger
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anna S. Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Angelika M. Starzer
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gregor Ortmayr
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Hannah C. Puhr
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ariane Steindl
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Robert Strassl
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Selma Tobudic
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Wolfgang W. Lamm
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Markus Raderer
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Manfred Mitterer
- Hemato-Oncological Day Hospital Unit, Franz Tappeiner Hospital, Meran/Merano, Italy
| | - Thorsten Fuereder
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Dominic Fong
- Hemato-Oncological Day Hospital Unit, Franz Tappeiner Hospital, Meran/Merano, Italy
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Law MF, Ho R, Law KWT, Cheung CKM. Gastrointestinal and hepatic side effects of potential treatment for COVID-19 and vaccination in patients with chronic liver diseases. World J Hepatol 2021; 13:1850-1874. [PMID: 35069994 PMCID: PMC8727202 DOI: 10.4254/wjh.v13.i12.1850] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/20/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
The outbreak of coronavirus disease 2019 (COVID-19) is a global pandemic. Many clinical trials have been performed to investigate potential treatments or vaccines for this disease to reduce the high morbidity and mortality. The drugs of higher interest include umifenovir, bromhexine, remdesivir, lopinavir/ritonavir, steroid, tocilizumab, interferon alpha or beta, ribavirin, fivapiravir, nitazoxanide, ivermectin, molnupiravir, hydroxychloroquine/chloroquine alone or in combination with azithromycin, and baricitinib. Gastrointestinal (GI) symptoms and liver dysfunction are frequently seen in patients with COVID-19, which can make it difficult to differentiate disease manifestations from treatment adverse effects. GI symptoms of COVID-19 include anorexia, dyspepsia, nausea, vomiting, diarrhea and abdominal pain. Liver injury can be a result of systemic inflammation or cytokine storm, or due to the adverse drug effects in patients who have been receiving different treatments. Regular monitoring of liver function should be performed. COVID-19 vaccines have been rapidly developed with different technologies including mRNA, viral vectors, inactivated viruses, recombinant DNA, protein subunits and live attenuated viruses. Patients with chronic liver disease or inflammatory bowel disease and liver transplant recipients are encouraged to receive vaccination as the benefits outweigh the risks. Vaccination against COVID-19 is also recommended to family members and healthcare professionals caring for these patients to reduce exposure to the severe acute respiratory syndrome coronavirus 2 virus.
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Affiliation(s)
- Man Fai Law
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
| | - Rita Ho
- Department of Medicine, North District Hospital, Hong Kong, China
| | | | - Carmen Ka Man Cheung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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42
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Gagelmann N, Passamonti F, Wolschke C, Massoud R, Niederwieser C, Adjallé R, Mora B, Ayuk F, Kröger N. Antibody response after vaccination against SARS-CoV-2 in adults with hematological malignancies: a systematic review and meta-analysis. Haematologica 2021; 107:1840-1849. [PMID: 34911284 PMCID: PMC9335098 DOI: 10.3324/haematol.2021.280163] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Indexed: 12/01/2022] Open
Abstract
Vaccines against SARS-CoV-2 have shown remarkable efficacy and thus constitute an important preventive option against coronavirus disease 2019 (COVID-19), especially in fragile patients. We aimed to systematically analyze the outcomes of patients with hematological malignancies who received vaccination and to identify specific groups with differences in outcomes. The primary end point was antibody response after full vaccination (2 doses of mRNA or one dose of vectorbased vaccines). We identified 49 studies comprising 11,086 individuals. Overall risk of bias was low. The pooled response for hematological malignancies was 64% (95% confidence interval [CI]: 59-69; I²=93%) versus 96% (95% CI: 92-97; I²=44%) for solid cancer and 98% (95% CI: 96-99; I²=55%) for healthy controls (P<0.001). Outcome was different across hematological malignancies (P<0.001). The pooled response was 50% (95% CI: 43-57; I²=84%) for chronic lymphocytic leukemia, 76% (95% CI: 67-83; I²=92%) for multiple myeloma, 83% (95% CI: 69-91; I²=85%) for myeloproliferative neoplasms, 91% (95% CI: 82-96; I²=12%) for Hodgkin lymphoma, and 58% (95% CI: 44-70; I²=84%) for aggressive and 61% (95% CI: 48-72; I²=85%) for indolent non-Hodgkin lymphoma. The pooled response for allogeneic and autologous hematopoietic cell transplantation was 82% and 83%, respectively. Being in remission and prior COVID-19 showed significantly higher responses. Low pooled response was identified for active treatment (35%), anti-CD20 therapy ≤1 year (15%), Bruton kinase inhibition (23%), venetoclax (26%), ruxolitinib (42%), and chimeric antigen receptor T-cell therapy (42%). Studies on timing, value of boosters, and long-term efficacy are needed. This study is registered with PROSPERO (clinicaltrials gov. Identifier: CRD42021279051).
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg.
| | | | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Radwan Massoud
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Niederwieser
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raissa Adjallé
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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43
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Floyd L, Elsayed ME, Seibt T, von Bergwelt-Baildon A, Seo P, Antiochos B, Kant S, Morris A, Dhaygude A, Schönermarck U, Geetha D. SARS-CoV-2 vaccine response in ANCA associated vasculitis patients. Kidney Int Rep 2021; 7:629-632. [PMID: 34926870 PMCID: PMC8664608 DOI: 10.1016/j.ekir.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- Lauren Floyd
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Mohamed E Elsayed
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Tobias Seibt
- Nephrology Division, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | | | - Philip Seo
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Brendan Antiochos
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sam Kant
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adam Morris
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ajay Dhaygude
- Department of Nephrology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ulf Schönermarck
- Nephrology Division, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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44
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Shields AM, Venkatachalam S, Shafeek S, Paneesha S, Ford M, Sheeran T, Kelly M, Qureshi I, Salhan B, Karim F, De Silva N, Stones J, Lee S, Khawaja J, Kaudlay PK, Whitmill R, Kakepoto GN, Parry HM, Moss P, Faustini SE, Richter AG, Drayson MT, Basu S. SARS-CoV-2 vaccine responses following CD20-depletion treatment in patients with haematological and rheumatological disease: a West Midlands Research Consortium study. Clin Exp Immunol 2021; 207:3-10. [PMID: 35020852 PMCID: PMC8767851 DOI: 10.1093/cei/uxab018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/29/2021] [Accepted: 11/08/2021] [Indexed: 12/15/2022] Open
Abstract
B-cell-depleting agents are among the most commonly used drugs to treat haemato-oncological and autoimmune diseases. They rapidly induce a state of peripheral B-cell aplasia with the potential to interfere with nascent vaccine responses, particularly to novel antigens. We have examined the relationship between B-cell reconstitution and SARS-CoV-2 vaccine responses in two cohorts of patients previously exposed to B-cell-depleting agents: a cohort of patients treated for haematological B-cell malignancy and another treated for rheumatological disease. B-cell depletion severely impairs vaccine responsiveness in the first 6 months after administration: SARS-CoV-2 antibody seroprevalence was 42.2% and 33.3% in the haemato-oncological patients and rheumatology patients, respectively and 22.7% in patients vaccinated while actively receiving anti-lymphoma chemotherapy. After the first 6 months, vaccine responsiveness significantly improved during early B-cell reconstitution; however, the kinetics of reconstitution was significantly faster in haemato-oncology patients. The AstraZeneca ChAdOx1 nCoV-19 vaccine and the Pfizer BioNTech 162b vaccine induced equivalent vaccine responses; however, shorter intervals between vaccine doses (<1 m) improved the magnitude of the antibody response in haeamto-oncology patients. In a subgroup of haemato-oncology patients, with historic exposure to B-cell-depleting agents (>36 m previously), vaccine non-responsiveness was independent of peripheral B-cell reconstitution. The findings have important implications for primary vaccination and booster vaccination strategies in individuals clinically vulnerable to SARS-CoV-2.
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Affiliation(s)
- Adrian M Shields
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Clinical Immunology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK,Correspondence: Adrian M. Shields, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | | | - Salim Shafeek
- Department of Haematology, Worcestershire Acute NHS Trust, Worcester, UK
| | - Shankara Paneesha
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Ford
- Department of Rheumatology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Tom Sheeran
- Department of Rheumatology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Melanie Kelly
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Iman Qureshi
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Beena Salhan
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Farheen Karim
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Neelakshi De Silva
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Jacqueline Stones
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Sophie Lee
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Jahanzeb Khawaja
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Richard Whitmill
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Helen M Parry
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sian E Faustini
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Alex G Richter
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Clinical Immunology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark T Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Department of Clinical Immunology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK,Mark T. Drayson, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | - Supratik Basu
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK,Faculty of Science & Engineering, University of Wolverhampton, Wolverhampton, UK,Supratik Basu, The Royal Wolverhampton NHS Trust, Wolverhampton, UK.
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45
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Smets I, Giovannoni G. Derisking CD20-therapies for long-term use. Mult Scler Relat Disord 2021; 57:103418. [PMID: 34902761 DOI: 10.1016/j.msard.2021.103418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/15/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022]
Abstract
Anti-CD20 have quickly become the mainstay in the treatment of multiple sclerosis (MS) and other neuroinflammatory conditions. However, when they are used as a maintenance therapy the balance between risks and benefits changes. In this review, we suggested six steps to derisk anti-CD20. Firstly and secondly, adequate infectious screening followed by vaccinations before starting anti-CD20 are paramount. Third, family planning needs to be discussed upfront with every woman of childbearing age. Fourth, infusion reactions should be adequately managed to avoid treatment interruption. After repeated infusions, it becomes important to detect and prevent anti-CD20-related adverse events. Fifth, we recommended measuring immunoglobulin levels and reviewing vaccinations annually as well as counselling adequate fever management. For female patients, we emphasised the importance to engage with the local breast cancer screening programs. Sixth, to fundamentally derisk anti-CD20 therapies, we need evidence-based approaches to reduce dosing intervals and guide retreatment.
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Affiliation(s)
- Ide Smets
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom.
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46
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Yarahmadi P, Alirezaei M, Forouzannia SM, Naser Moghadasi A. The Outcome of COVID-19 in Patients with a History of Taking Rituximab: A Narrative Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2021; 46:411-419. [PMID: 34840381 PMCID: PMC8611224 DOI: 10.30476/ijms.2021.88717.1946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/26/2021] [Accepted: 03/13/2021] [Indexed: 01/16/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a recently emerging disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Notably, the safety of immunosuppressive medications is a major concern during an infectious disease pandemic. Rituximab (RTX), as a monoclonal antibody against CD20 molecule, is widely used for the treatment of various diseases, mostly autoimmune diseases and some malignancies. Previous studies indicated that RTX, as an immunosuppressive medication, may be associated with the increased risk of infections. Moreover, given the wide use of RTX, a necessity of determining the different aspects of RTX use in the COVID-19 era is strongly felt. We reviewed current studies on the clinical courses of patients with SARS-CoV-2 infection. It appears that the use of RTX does not increase morbidity and mortality in most patients. However, underlying diseases and other concomitant medications may play a role in the disease course, while the concerns of vaccine efficacy in patients receiving RTX still need to be addressed. Therefore, more controlled studies are needed for a better conclusion.
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Affiliation(s)
- Pourya Yarahmadi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Alirezaei
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Forouzannia
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abdorreza Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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47
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Choi PY, Merriman E, Bennett A, Enjeti AK, Tan CW, Goncalves I, Hsu D, Bird R. Consensus guidelines for the management of adult immune thrombocytopenia in Australia and New Zealand. Med J Aust 2021; 216:43-52. [PMID: 34628650 PMCID: PMC9293212 DOI: 10.5694/mja2.51284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 01/21/2023]
Abstract
Introduction The absence of high quality evidence for basic clinical dilemmas in immune thrombocytopenic purpura (ITP) underlines the need for contemporary guidelines relevant to the local treatment context. ITP is diagnosed by exclusions, with a hallmark laboratory finding of isolated thrombocytopenia. Main recommendations Bleeding, family and medication histories and a review of historical investigations are required to gauge the bleeding risk and possible hereditary syndromes. Beyond the platelet count, the decision to treat is affected by individual bleeding risk, disease stage, side effects of treatment, concomitant medications, and patient preference. Treatment is aimed at achieving a platelet count > 20 × 109/L, and avoidance of severe bleeding. Steroids are the standard first line treatment, with either 6‐week courses of tapering prednisone or repeated courses of high dose dexamethasone providing equivalent efficacy. Intravenous immunoglobulin can be used periprocedurally or as first line therapy in combination with steroids. Changes in management as a result of this statement There is no consensus on choice of second line treatments. Options with the most robust evidence include splenectomy, rituximab and thrombopoietin receptor agonists. Other therapies include azathioprine, mycophenolate mofetil, dapsone and vinca alkaloids. Given that up to one‐third of patients achieve a satisfactory haemostatic response, splenectomy should be delayed for at least 12 months if possible. In life‐threatening bleeding, we recommend platelet transfusions to achieve haemostasis, along with intravenous immunoglobulin and high dose steroids.
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Affiliation(s)
- Philip Yi Choi
- Canberra Hospital, Canberra, ACT.,Australian National University, Canberra, ACT
| | | | - Ashwini Bennett
- Monash Medical Centre, Melbourne, VIC.,Monash University, Melbourne, VIC
| | - Anoop K Enjeti
- Calvary Mater Hospital, Newcastle, NSW.,University of Newcastle, Newcastle, NSW
| | - Chee Wee Tan
- Royal Adelaide Hospital, Adelaide, SA.,SA Pathology, Adelaide, SA
| | - Isaac Goncalves
- Peter MacCallum Cancer Centre, Melbourne, VIC.,Royal Melbourne Hospital, Melbourne, VIC
| | - Danny Hsu
- South Western Sydney Local Health District, Sydney, NSW.,University of New South Wales, Sydney, NSW
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48
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Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Williams EA, Mikuls TR. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 3. Arthritis Rheumatol 2021; 73:e60-e75. [PMID: 34346564 PMCID: PMC8426685 DOI: 10.1002/art.41928] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the use of coronavirus disease 2019 (COVID-19) vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS Despite a paucity of direct evidence, 74 draft guidance statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION These guidance statements, made in the context of limited clinical data, are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.
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Affiliation(s)
| | - Sindhu R. Johnson
- Toronto Western HospitalMount Sinai Hospital, and University of TorontoTorontoOntarioCanada
| | - Donald D. Anthony
- Louis Stokes Cleveland VA Medical CenterMetroHealth Medical Center, and Case Western Reserve UniversityClevelandOhioUnited States
| | - Reuben J. Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical CenterDallas
| | | | - Anne R. Bass
- Hospital for Special Surgery and Weill Cornell MedicineNew YorkNew YorkUnited States
| | | | | | - Rafael Harpaz
- Harpaz Herman ConsultantsAtlantaGeorgiaUnited States
| | | | | | - Amy S. Turner
- American College of RheumatologyAtlantaGeorgiaUnited States
| | | | - Ted R. Mikuls
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care SystemOmaha
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49
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SARS-CoV-2 Vaccination and Immune Thrombocytopenia in de novo and pre-existing ITP patients. Blood 2021; 139:1564-1574. [PMID: 34587251 PMCID: PMC8483984 DOI: 10.1182/blood.2021013411] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
Cases of de novo immune thrombocytopenia (ITP) - including a fatality - following SARS-CoV-2 vaccination in previously healthy recipients led to studying its impact in pre-existing ITP. In this study, four data sources were analyzed: the Vaccine Adverse Events Reporting System (VAERS) for cases of de novo ITP; a ten-center retrospective study of adults with pre-existing ITP receiving SARS-CoV-2 vaccination; and surveys distributed by the Platelet Disorder Support Association (PDSA, United States) and the United Kingdom (UK) ITP Support Association. Seventy-seven de novo ITP cases were identified in VAERS, presenting with median platelet count of 3 [1-9] x109/L approximately 1-week post-vaccination. Of 28 patients with available data, 26 responded to treatment with corticosteroids and/or intravenous immunoglobulin (IVIG), and/or platelet transfusions. Among 109 patients with pre-existing ITP who received a SARS-CoV-2 vaccine, 19 experienced an ITP exacerbation (any of: ≥50% decline in platelet count, nadir platelet count <30x109/L with >20% decrease from baseline, and/or use of rescue therapy) following the first dose and 14 of 70 after a second dose. Splenectomized persons and those who received 5 or more prior lines of therapy were at highest risk of ITP exacerbation. Fifteen patients received and responded to rescue treatment. In surveys of both 57 PDSA and 43 UK ITP patients, prior splenectomy was associated with worsened thrombocytopenia. ITP may worsen in pre-existing ITP or be identified de novo post-SARS-CoV2-vaccination; both situations responded well to treatment. Proactive monitoring of patients with known ITP, especially those post-splenectomy and with more refractory disease, is indicated.
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Diks AM, Overduin LA, van Leenen LD, Slobbe L, Jolink H, Visser LG, van Dongen JJM, Berkowska MA. B-Cell Immunophenotyping to Predict Vaccination Outcome in the Immunocompromised - A Systematic Review. Front Immunol 2021; 12:690328. [PMID: 34557188 PMCID: PMC8452967 DOI: 10.3389/fimmu.2021.690328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/13/2021] [Indexed: 11/13/2022] Open
Abstract
Vaccination is the most effective measure to prevent infections in the general population. Its efficiency strongly depends on the function and composition of the immune system. If the immune system lacks critical components, patients will not be fully protected despite a completed vaccination schedule. Antigen-specific serum immunoglobulin levels are broadly used correlates of protection. These are the products of terminally differentiated B cells - plasma cells. Here we reviewed the literature on how aberrancies in B-cell composition and function influence immune responses to vaccinations. In a search through five major literature databases, 6,537 unique articles published from 2000 and onwards were identified. 75 articles were included along three major research lines: extremities of life, immunodeficiency and immunosuppression. Details of the protocol can be found in the International Prospective Register of Systematic Reviews [PROSPERO (registration number CRD42021226683)]. The majority of articles investigated immune responses in adults, in which vaccinations against pneumococci and influenza were strongly represented. Lack of baseline information was the most common reason of exclusion. Irrespective of study group, three parameters measured at baseline seemed to have a predictive value in assessing vaccine efficacy: (1) distribution of B-cell subsets (mostly a reduction in memory B cells), (2) presence of exhausted/activated B cells, or B cells with an aberrant phenotype, and (3) pre-existing immunological memory. In this review we showed how pre-immunization (baseline) knowledge of circulating B cells can be used to predict vaccination efficacy. We hope that this overview will contribute to optimizing vaccination strategies, especially in immunocompromised patients.
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Affiliation(s)
- Annieck M Diks
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Lisanne A Overduin
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands.,Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Laurens D van Leenen
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Lennert Slobbe
- Department of Internal Medicine, Section of Infectious Diseases, Institute for Tropical Diseases, Erasmus Medical Center (MC), Rotterdam, Netherlands
| | - Hetty Jolink
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Leonardus G Visser
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | | | - Magdalena A Berkowska
- Department of Immunology, Leiden University Medical Center (LUMC), Leiden, Netherlands
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