B-cell depleting medication increases COVID-19 breakthrough infection outcome risk

Nearly half of the rheumatic patients in need of hospitalisation for a SARS-CoV-2 infection after full vaccination were on treatment with CD20 inhibitors. Additional protective measures for this population at risk should be considered.

“COVID-19 vaccinations are recommended and usually well tolerated and efficacious among people with rheumatic disease. However, lab-based studies using surrogate markers of protection against COVID-19 have demonstrated reduced vaccine immunogenicity in people on certain immunosuppressant medications,” Prof. Jean Liew (Boston University, MA, USA) explained the need for further knowledge to effectively counsel immunocompromised patients [1].

The current study analysed data from the Global Rheumatology Alliance registry to shed further light on this matter. The investigation included nearly 200 patients with SARS-CoV-2 infection after vaccination and their outcomes in terms of hospitalisation, the need for oxygen, and death. The 87 participants who were defined as fully vaccinated had received either a single vaccination (single-dose vaccine) or the second dose (2-dose series) at least 14 days before inclusion. The partially vaccinated (n=110) definition comprised patients with a single-dose vaccination within the previous 13 days or 1 dose of a 2-dose series ≥14 days before. Participants had a mean age of 53.2 years, 72.6% were women, and 55.3% White. Over 40% suffered from rheumatoid arthritis, 15.4% from systemic lupus erythematosus, and 9.6% had psoriatic arthritis. Treatment prior to vaccination included methotrexate (27.4%), leflunomide (6.6%), azathioprine (5.1%), mycophenolate (10.7%), TNF inhibitors (18.8%), CD20 inhibitors (11.2%), and JAK inhibitors (6.1%); 33% were on glucocorticoids. “Most common comorbidities were hypertension, obesity, and lung disease and the majority received mRNA vaccines,” Prof. Liew indicated.

In general, 51 (25.9%) of the study participants were hospitalised and 9 (4.6%) died. In fully-vaccinated patients, of whom 28% were on glucocorticoids and 18% on CD20 inhibitors, the mean time to infection was 111.8 days. “All 4 individuals who required invasive ventilation, subsequently died, as well as 1 individual on non-invasive ventilation,” stated Prof. Liew. Within the subgroup of fully-vaccinated patients who needed hospitalisation due to COVID-19, 45.5% received CD20 inhibitors for their rheumatic disease. “We did not find meaningful differences in glucocorticoid use among breakthrough infections by hospitalisation status, and we had few patients on other medications such as TNF inhibitors or methotrexate,” Prof. Liew pointed out. Lung disease as a comorbidity was present in 36% of fully-vaccinated in-patients with a breakthrough infection.

“These findings support prior laboratory data that people on certain rheumatic disease medications, such as CD20 inhibitors and mycophenolate, may be at higher risk for poor outcomes of breakthrough SARS-CoV-2 infection versus the general population. So, additional risk mitigation strategies including additional vaccine doses, monoclonal antibody treatment, and possibly oral antivirals may be needed to protect this high-risk population,” she concluded.

1. Liew JW. SARS-CoV-2 infections among vaccinated individuals with rheumatic disease: results from the COVID-19 Global Rheumatology Alliance provider registry. Abstract L04, ACR Convergence 2021, 3–10 November.

 

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Posted on 14 January, 2022