Withholding mycophenolate mofetil for 1 week improves COVID-19 vaccine efficacy in lupus
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Patients with systemic lupus erythematosus who are vaccinated for COVID-19 demonstrate reduced antibody levels compared with vaccinated controls, according to data published in Arthritis Care & Research.
However, withholding mycophenolate mofetil for 1 week post-vaccination was found to improve vaccine efficacy, researchers added.
“Both SLE itself and the use of some immunosuppressant medications may impact the risk of COVID,” Michelle Petri, MD, MPH, of the Johns Hopkins University School of Medicine, and colleagues wrote. “In particular, corticosteroids and B-cell depleting biologics such as rituximab impair vaccine response.”
To examine the impact of immunosuppressive therapy on COVID-19 vaccine response in patients with SLE, Petri and colleagues analyzed data from the Hopkins Lupus Cohort. According to the researchers, patients in this cohort are seen by physicians every 3 months. The analysis included patients who met the American College of Rheumatology classification criteria for SLE and provided data on vaccination status for COVID-19. All patients were required to have received two doses of an mRNA COVID-19 vaccine.
Following enrollment, providers collected serum samples from patients every 3 months. At each quarterly visit, patients were evaluated using the SLE Disease Activity Index (SLEDAI), physician’s global assessment and laboratory values. COVID-19 infection was verified through health record searches.
Meanwhile, health care workers who participated in a study visit between March 10 and April 8, 2021, were included in the analysis as a control group. Individuals in this group were required to have a serum sample collected at least 14days after receiving the second dose of an mRNA COVID-19 vaccine.
The analysis included a total of 365 observations from 334 patients with SLE, as well as 2,235 observations from 1,887 health care workers in the control group. In general, all patients with SLE demonstrated lower levels of vaccine IgG than participants from the control group, according to the researchers. However, more specifically, patients with SLE who had received immunosuppressants demonstrated lower antibody levels than those with SLE who did not receive immunosuppressive therapy.
In addition, patients who delayed mycophenolate mofetil for 1 week following vaccination experienced “significantly” higher IgG levels and did not experience more disease flares, the researchers wrote.
“We found that holding mycophenolate for the day of the vaccine and the following 6 days improved vaccine response without the patient paying a price in terms of increased lupus activity,” Petri told Healio. “This is a shorter hold than previously recommended in vaccination guidelines, and likely will hold true as more mRNA vaccines are developed in the future.”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Prior to the COVID-19 pandemic, vaccinating immunosuppressed individuals was an area of interest but often did not have good data. Reviews using literature searches are often the way in which the data is examined to determine the efficacy and safety of vaccinating an immunosuppressed group. In one paper, 50 studies were reviewed to determine the efficacy and safety of the hepatitis A vaccine in patients on immunosuppressants. Only 17 studies met eligibility criteria for review and only nine met criteria for meta-analysis.
Another review on the efficacy and safety of measles, mumps, rubella and varicella live viral vaccines in transplant recipients receiving immunosuppressive drugs reviewed “a small number of low-quality studies,” and had inconclusive results. They did note that the majority of data indicated anti-B-cell antibodies had a more severe and prolonged negative effect on vaccine efficacy than other agents with a different mode of action.
When COVID-19 vaccines were initially in clinical trials, immunocompromised conditions and/or a history of autoimmune disease were exclusion criteria. A preliminary report from an ongoing McGill study revealed a lower seropositivity response to the first dose of an mRNA COVID-19 vaccine in patients with rheumatic diseases — 67.7% in rheumatoid arthritis, 34.8% in systemic lupus erythematosus, and 87.5% in other rheumatic diseases — with an improved response with the second dose.
A meta-analysis of 82 studies with immunocompromised individuals found a lower seroconversion rate in this group compared to immunocompetent individuals and an improvement with the second dose. Organ transplant recipients had the lowest conversion rate.
The present study is very helpful for rheumatology as we need guidelines for vaccination in our immunosuppressed patients. This is very helpful data for our patients on mycophenolate. Hopefully, more studies will be forthcoming on this important topic.
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