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Troldborg A, Thomsen MK, Bartels LE, Andersen JB, Vils SR, Jørgensen CM, Johannesen AD, Hermansen MLF, Mikkelsen S, Erikstrup C, Hauge EM, Ammitzbøll C. POS0261 TIME SINCE LAST RITUXIMAB TREATMENT IS ESSENTIAL FOR DEVELOPING A HUMORAL RESPONSE TO THE COVID-19 MRNA VACCINE IN PATIENTS WITH RHEUMATIC DISEASES. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundConcerns about Rituximab (RTX) treatment and potentially inadequate vaccine response were aired early in the pandemic, and initial data seem to support this concern (1). So far, studies regarding rheumatic patients and the COVID-19 vaccines have included a relatively small number of patients receiving rituximab.ObjectivesWe aimed to investigate if patients with rheumatic diseases treated with RTX raise a serological response towards the COVID-19 mRNA vaccines and to elucidate the influence of time since the last dose RTX before vaccination on this response.MethodsWe included 201 patients followed at the Department of Rheumatology, Aarhus University Hospital. All had been treated with RTX in the period 2017-2021, and had finished a two-dose COVID-19 mRNA vaccination. All patients and 44 blood donors had total antibodies against SARS-CoV2 spike protein measured. Univariate and multivariate logistic regression were used.ResultsPatients were predominantly female (67%) with a median age of 62 years. The most frequent diagnosis was ANCA-associated vasculitis (32%), rheumatoid arthritis (31%), and myositis (14%), and 97% had the Pfizer/Biontic vaccine. Median number of RTX infusions were 5 (IQR 2-8), with a cumulative dose of 4g (2-8), and 72% had received RTX within the last 15 months. Prednisone was used by 43%, followed by methotrexate (25%), hydroxychloroquine (11%) and azathioprine (10%).We observed a time-dependent increase in antibody response as the interval from the last RTX treatment to vaccination increased (Table 1). Only 17.3% of patients developed a detectable antibody response after receiving their vaccination 6 months or less after their previous RTX treatment (Figure 1). Positive antibody response increased to 66.7% in patients who had RTX 9-12 months before vaccination. Neither cumulative treatment time nor cumulative RTX dose seemed to influence the serological response to the vaccine (Table 1). Thus, even in patients who have received RTX for a substantial time, expanding time-since-last-RTX treatment could prove beneficial for increasing the chance of a serological response. We further found that “months between last Rtx and vaccination”, prednisone and azathioprine treatment were alle negatively associated with antibody response in a multivariate logistic regression analysis(Table 1). All blood donors (100%) had detectable antibodies after vaccination.Table 1.Logistic regression analysis with precense of SARS-CoV-2 antibodies after mRNA vaccination as dependent varaible.UnivariateOR95% CIP-valueSex, female = ref.0.910.50 - 1.670.77Age, years0.980.96 - 1.000.09Diagnosis1.050.99 – 1.130.08Months between last RTX and vaccination1.061.03 - 1.09<0.001Total number of RTX infusions0.960.92 - 1.010.10Total dose of RTX, mg0.970.92 - 1.020.18Time from first to last RTX treatment1.001.00 - 1.000.57No DMARD treatment0.940.50 - 1.780.85Prednisone, dose in mg0.910.85 - 0.990.02Methotrexate1.710.90 - 3.250.10Hydroxychloroquine0.870.35 - 2.190.77Azathioprine0.230.06 - 0.800.02Multivariate modelMonths between last Rtx and vaccination1.081.04 - 1.11<0.001Prednisone treatment, mg0.910.84 - 0.990.03Azathioprine treatment0.100.02 - 0.440.002All significant variables in the univariate analysis were included in the multivariate model.ConclusionIn conclusion, patients with rheumatic diseases treated with RTX have a severely impaired serological response towards the COVID-19 mRNA vaccine. This is especially true if the interval between RTX treatment and vaccination is less than 9 months. For the majority of RTX treated patients, the recommended six months since last RTX is insufficient to develop a humoral response to COVID-19 mRNA vaccines. Our data suggest that the current recommendations of a 6 months interval should be revised.References[1]Ammitzbøll C, et al. Impaired antibody response to the BNT162b2 mRNA COVID-19 vaccine in patients with Systemic Lupus Erythematosus and Rheumatoid Arthritis. ACR Open Rheumatol. 2021;Disclosure of InterestsNone declared
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Ammitzbøll C, Thomsen MK, Andersen JB, Bartels LE, Hermansen MLF, Johannesen AD, Jørgensen CM, Mikkelsen S, Vils SR, Erikstrup C, Hauge EM, Troldborg A. POS1198 VACCINATION AGAINST COVID-19 SHOULD BE ENCOURAGED IN PATIENTS WITH RHEUMATIC DISEASE, AS MOST PATIENTS DEVELOP A SEROLOGICAL RESPONSE AGAINST THE VACCINE AND VACCINATION REDUCES SELF-IMPOSED ISOLATION AND SHIELDING BEHAVIOR. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundVaccine trials of the SARS-CoV-2 mRNA vaccines were encouraging but excluded most patients with rheumatic diseases (RD) and patients treated with immunosuppressive therapy. However, reports of a more severe COVID-19 disease course in patients with RDs prompted strategies for expediting vaccination of RD patients in most countries.In addition to the impact experienced by most people of the pandemic, patients with RDs were adversely impacted by the potential risk of severe COVID-19 due to their disease and immunosuppressive treatment. Fear of COVID-19 led to disproportionate anxiety, self-isolation, and shielding behavior for many RD patients at the beginning of the pandemic.ObjectivesWe investigated antibody levels in serum against SARS-CoV-2 after a two-dose vaccination with an mRNA vaccine in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Further, we examined the association between reactogenicity and immunogenicity and how vaccination influenced patient behavior concerning fear of COVID-19 and shielding.MethodsPatients with SLE or RA from the COPANARD (Corona PANdemic Autoimmune Rheumatic Disease)1 cohort received two doses of an mRNA vaccine between January and August 2021 and had total antibodies against SARS-CoV-2 measured before vaccination and 2 and 9 weeks after the second vaccination. In addition, patients answered an electronic questionnaire before and eight weeks after vaccination concerning behavior, anxiety, and symptoms of depression (PHQ-9).ResultsThree-hundred-and-three patients and 44 blood donors (healthy controls) were included. Significantly fewer patients (90%) had measurable antibodies against SARS-CoV-2 compared to blood donors (100%) after the second vaccination (p<0.001) (Figure 1). Treatment with Rituximab was the strongest predictor of unfavorable vaccine response, as only 27% were seropositive after vaccination. We found a negative effect of prednisone and methotrexate but no effect of age, comorbidity, or pausing medication on seroconversion. Patients experienced significant improvement after vaccination in 10 out of 12 questions regarding behavior and fear of COVID-19, but no change was observed in symptoms of depression (p=0.62) or anxiety (p=0.46).Figure 1.Total antibody response against SARS-CoV-2 after two mRNA vaccines. Antibody response against mRNA COVID-19 vaccine pre-vaccination, 1 and 9 weeks after in patients with rheumatic diseases and 5-6 weeks after vaccination in blood donors. (A) Percentage with measurable SARS-CoV-2 antibody results after vaccination. (B) Levels of SARS-CoV-2 antibodies in serum.ConclusionThe majority of patients with SLE or RA had a measurable serological response to the COVID-19 mRNA vaccine after two doses. Treatment with Rituximab was the strongest predictor of no seroconversion.Our findings warrant encouragement of vaccination against COVID-19 for patients with RD, as most patients benefits with both a serological immune response and reduced isolation and shielding behavior.References[1]Ammitzbøll C, Andersen JB, Vils SR, Mistegaard CE, Mikkelsen S, Erikstrup C, Thomsen MK, Hauge EM, Troldborg A. Arthritis Care Res (Hoboken). 2021 May 31:10.1002/acr.24716. doi: 10.1002/acr.24716. Online ahead of print.Disclosure of InterestsNone declared
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Bartels LE, Pedersen AB, Kristensen NR, Jepsen P, Vilstrup H, Stengaard-Pedersen K, Dahlerup JF. Helicobacter pylori infection is not associated with rheumatoid arthritis. Scand J Rheumatol 2018; 48:24-31. [DOI: 10.1080/03009742.2018.1464205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- LE Bartels
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - AB Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - NR Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - P Jepsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - H Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - JF Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Bendix M, Dige A, Deleuran B, Dahlerup JF, Jørgensen SP, Bartels LE, Husted LB, Harsløf T, Langdahl B, Agnholt J. Flow cytometry detection of vitamin D receptor changes during vitamin D treatment in Crohn's disease. Clin Exp Immunol 2015; 181:19-28. [PMID: 25707738 DOI: 10.1111/cei.12613] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/29/2015] [Accepted: 02/18/2015] [Indexed: 12/14/2022] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disease associated with a dysregulated T cell response towards intestinal microflora. Vitamin D has immune modulatory effects on T cells through the nuclear vitamin D receptor (VDR) in vitro. It is unclear how oral vitamin D treatment affects VDR expression. The aim of this study was to establish a flow cytometry protocol, including nuclear and cytoplasmic VDR expression, and to investigate the effects of vitamin D treatment on T cell VDR expression in CD patients. The flow cytometry protocol for VDR staining was developed using the human acute monocytic leukaemia cell line (THP-1). The protocol was evaluated in anti-CD3/CD28-stimulated peripheral blood mononuclear cells (PBMCs) from vitamin D3- (n = 9) and placebo-treated (n = 9) CD patients. Anti-VDR-stained PBMCs were examined by flow cytometry, and their cytokine production was determined by cytokine bead array. VDR, CYP27B1 and RXRα mRNA expression levels in CD4(+) T cells were measured by quantitative reverse transcriptase polymerase chain reaction. The flow cytometry protocol enabled detection of cytoplasmic and nuclear VDR expression. The results were confirmed by confocal microscopy and supported by correlation with VDR mRNA expression. VDR expression in CD4(+) T cells increased following stimulation. This VDR up-regulation was inhibited with 30% by vitamin D treatment compared to placebo in CD patients (P = 0027). VDR expression was correlated with in-vitro interferon-γ production in stimulated PBMCs (P = 0.01). Flow cytometry is a useful method with which to measure intracellular VDR expression. Vitamin D treatment in CD patients reduces T cell receptor-mediated VDR up-regulation.
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Affiliation(s)
- M Bendix
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - A Dige
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - B Deleuran
- Department of Immunology, Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| | - J F Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - S P Jørgensen
- Department of Medicine, Regional Hospital Horsens, Horsens, Denmark
| | - L E Bartels
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - L B Husted
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - T Harsløf
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - B Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - J Agnholt
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Bendix-Struve M, Bartels LE, Agnholt J, Dige A, Jørgensen SP, Dahlerup JF. Vitamin D3 treatment of Crohn's disease patients increases stimulated T cell IL-6 production and proliferation. Aliment Pharmacol Ther 2010; 32:1364-72. [PMID: 21050239 DOI: 10.1111/j.1365-2036.2010.04463.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Vitamin D3 has shown immune-modulating effects in CD4+ T cells from Crohn's disease patients in vitro. AIM To investigate the effects of in vivo vitamin D3 treatment on T cells in Crohn's disease patients. METHODS Peripheral blood mononuclear cells (PBMC) were isolated at week 0 and at week 26 from 10 vitamin D3- and 10 placebo-treated Crohn's disease patients participating in a randomized, placebo-controlled, clinical trial study. Monocyte-depleted PBMC were stimulated with anti-CD3 and anti-CD28, and cultured for 7, days, to investigate CD4+ T-cell proliferation and T-cell cytokine production. RESULTS In vitamin D3-treated patients, the median 25-hydroxyvitamin D3 levels increased 70 nmol/L compared with -5 nmol/L in the placebo group. Vitamin D3 treatment increased interleukin-6 production (delta = 188 pg/mL, range: -444 to 4071) compared with a decrease in the placebo group (delta = -896 pg/mL, range: -3841 to 1323) (P < 0.02, Wilcoxon rank sum test). Interestingly, vitamin D3 increased the amount of proliferating stimulated CD4+ T cells from median 41% (range: 10-75%) to 56% (range: 26-77%) (P = 0.02, Wilcoxon rank sum test). CONCLUSIONS Vitamin D3 treatment of Crohn's disease patients increased the IL-6 levels. Interestingly, vitamin D3 treatment enhanced the CD4+ T cell proliferation.
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Affiliation(s)
- M Bendix-Struve
- Department of Medicine V, Aarhus University Hospital, Denmark.
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Jørgensen SP, Agnholt J, Glerup H, Lyhne S, Villadsen GE, Hvas CL, Bartels LE, Kelsen J, Christensen LA, Dahlerup JF. Clinical trial: vitamin D3 treatment in Crohn's disease - a randomized double-blind placebo-controlled study. Aliment Pharmacol Ther 2010; 32:377-83. [PMID: 20491740 DOI: 10.1111/j.1365-2036.2010.04355.x] [Citation(s) in RCA: 230] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Vitamin D has immune-regulatory functions in experimental colitis, and low vitamin D levels are present in Crohn's disease. AIM To assess the effectiveness of vitamin D3 treatment in Crohn's disease with regard to improved disease course. METHODS We performed a randomized double-blind placebo-controlled trial to assess the benefits of oral vitamin D3 treatment in Crohn's disease. We included 108 patients with Crohn's disease in remission, of which fourteen were excluded later. Patients were randomized to receive either 1200 IU vitamin D3 (n = 46) or placebo (n = 48) once daily during 12 months. The primary endpoint was clinical relapse. RESULTS Oral vitamin D3 treatment with 1200 IU daily increased serum 25OHD from mean 69 nmol/L [standard deviation (s.d.) 31 nmol/L] to mean 96 nmol/L (s.d. 27 nmol/L) after 3 months (P < 0.001). The relapse rate was lower among patients treated with vitamin D3 (6/46 or 13%) than among patients treated with placebo (14/48 or 29%), (P = 0.06). CONCLUSIONS Oral supplementation with 1200 IE vitamin D3 significantly increased serum vitamin D levels and insignificantly reduced the risk of relapse from 29% to 13%, (P = 0.06). Given that vitamin D3 treatment might be effective in Crohn's disease, we suggest larger studies to elucidate this matter further. ClinicalTrial.gov(NCT00122184).
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Affiliation(s)
- S P Jørgensen
- Department of Medicine V, Aarhus University Hospital, Denmark.
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