Holding abatacept, TNFi unnecessary for receiving COVID-19 booster
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SAN DIEGO — COVID-19 vaccine boosters led to a significantly increased antibody response in patients using abatacept or TNF inhibitors regardless of whether they held medication, according to data presented at ACR Convergence 2023.
“Patients on immunomodulatory therapies who rheumatologists see and treat may be at increased risk for severe COVID-19 illness that may include hospitalization, ICU stays and even mortality,” Jeffrey Curtis, MD, MS, MPH, of the University of Alabama at Birmingham, told attendees. “We know from some vaccine literature that there is a variety of medications, including methotrexate, that had been shown in studies to blunt immune responses if you are on those therapies at the time that you get vaccinated.
“In light of that, we started to think maybe it could be a good idea to have temporary cessation of one or more of the immunomodulatory medicines that we use at the time people are given vaccines,” he added. “But we don’t know whether that same idea would apply to COVID vaccination or COVID boosting.”
To analyze COVID-19 vaccine booster responses among patients with rheumatic diseases using immunomodulatory therapies — and specifically whether those holding therapy for 2 weeks following a booster demonstrated improved response — Curtis and colleagues conducted the COVID Vaccine Response (COVER) trial. In this multicenter, randomized controlled trial, the researchers enrolled patients with either rheumatoid arthritis or spondyloarthritis from the Excellence Network in Rheumatology (ENRGY), a large practice-based research network of rheumatologists in the United States.
Included patients were randomized to maintain or hold their medication — in this analysis, either abatacept (Orencia, Bristol Myers Squibb) or a TNF inhibitor — for 2 weeks after receiving a COVID-19 vaccine booster dose. In all, 142 patients were receiving abatacept, while 121 were using TNF inhibitors. All included patients had received their primary doses of an mRNA COVID-19 vaccine.
The researchers assessed patients’ anti-receptor binding domain (RBD) IgG antibody levels before and after the booster dose. In addition, they used linear regression to compare changes in COVID-19 RBD antibody levels between the two medication groups, adjusting for age, sex, BMI, methotrexate use and the number of prior vaccine doses.
According to the researchers, RBD antibody titers were significantly increased after patients received the COVID-19 vaccine booster in both the abatacept ( P = .0029 among those who held for 2 weeks; P = .03604 for those who continued therapy) and TNF-inhibitor (P < .0001 for both) groups.
Although patients who maintained their abatacept regimen demonstrated a numerically lower increase in anti-RBD antibody titers vs. those who held their medication, the linear regression analysis demonstrated that any such differences were not significant in either medication group. This was seen in both the unadjusted analysis and after adjusting for demographic and clinical factors. The researchers additionally reported “no significant interaction in the effect of holding or continuing” drug regimens between the abatacept and TNF inhibitor cohorts (interaction P = 0.55).
“It does not appear that holding abatacept or TNF inhibitors for 2 weeks when you give patients a COVID booster is warranted,” Curtis said. “It’s based on humoral immunogenicity and we’re not yet measuring cell-mediated immunity.”
Perspective
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Carlos M. Alonso, MD, FACR, RhMSUS
This study provides important data regarding the effectiveness of COVID-19 booster shots in patients with rheumatoid arthritis or spondyloarthritis using TNF inhibitors or abatacept (Orencia, Bristol Myers Squibb). In this research, the difference in humoral response after inoculation was not significant, with both groups achieving a significant increase in antibody response to the booster.
For practicing rheumatologists, patient calls inquiring about what to do with their medications before vaccine administration are a common occurrence. Our goal is to avoid disease flare ups while achieving adequate antibody response to the vaccine. Evidence-based data is weak at times and varies depending on the type of vaccine and immunosuppression being used. We conclude that a lower humoral response to a vaccine translates into worse outcomes when patients are exposed to the corresponding infectious agent.
As a rule of thumb, we try to vaccinate prior to initiating the immunosuppressive drug if possible. If the patient is already on treatment, we vaccinate before the next scheduled dose of the drug and, depending on the specific case, hold the next one or two doses. This study suggests that holding abatacept or TNF inhibitors after a COVID-19 booster is not warranted. As more data becomes available, we should continue adjusting our clinical practices around immunosuppressive agents and specific vaccinations.
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Curtis J. Abstract 1673. Presented at: ACR Convergence 2023; Nov. 10-15, 2023; San Diego.
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