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Vaccination strategies for people with rheumatic diseases have received significant scrutiny in regard to COVID-19 vaccines. People with rheumatoid arthritis (RA) are at higher risk for adverse outcomes related to COVID-19 but also may have reduced immunogenicity to COVID-19 vaccines; thus, temporary withdrawal of medications has been suggested. Renner Araujo and colleagues report the results of a single-center randomized study from Brazil looking at the immune response to two doses of the Sinovac-CoronaVac vaccine in 129 patients with RA. They found that those who stopped methotrexate for 2 weeks after both doses had a higher rate of seroconversion, based on immunoglobulin (Ig) G positivity (78% vs. 54%), than those who remained on methotrexate. Antibody titers were also higher in the "methotrexate-hold" group. Flare rates were higher, based on the Clinical Disease Activity Index (CDAI) — though not on the Disease Activity Scale-28 (DAS-28) — in patients who withdrew from methotrexate. This information is interesting with respect to the use of future inactivated virus vaccines, though its applicability to mRNA vaccines, other than predicting the possibility of flare, is less clear. However, the results could be useful in informed discussions and decision-making regarding withdrawing immunosuppressive drugs.
Some people with rheumatic diseases have been concerned about flares of disease activity related to COVID-19 vaccination. Tedeschi and colleagues conducted a prospective observational study of 71 patients with RA who were previously inoculated against COVID-19 with two mRNA vaccine doses or one adenovirus vector vaccine dose. Using the patient-reported Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5), they measured disease activity weekly from study enrollment through 4 weeks after an additional dose. They did not find any change in mean RADAI-5 score between pre- and post additional dose, nor was disease activity different in patients who stopped disease-modifying antirheumatic drugs (DMARD) compared with those who did not. The study also examined flow cytometry of lymphocyte populations among a subset of these patients (n = 27) and found no significant differences in T peripheral helper cells, T follicular helper cells, age-associated B cells, and plasmablasts among patients before and after the additional vaccine dose. Though the flow cytometry data are difficult to generalize, given the presumed heterogeneity and small number of patients, the lack of change in RA disease activity after the additional vaccine dose is reassuring.
Achievement of remission in patients with RA is also an area of continued interest, especially because of the difficulty of reaching this target under real-world conditions. Larid and colleagues report the prognostic factors of remission and characteristics of 215 patients with RA over 7 years of follow-up at an academic hospital in France. Notably, 33% of patients were in remission at 1 year, of whom 76% remained in remission at 7 years. However, 48% of patients who were not in remission at 1 year achieved remission at 7 years; 58% of study participants were in remission in total at 7 years of follow-up. Those in remission were more frequently being prescribed both conventional synthetic DMARD (csDMARD) and biologic DMARD (bDMARD), while those not in remission at 7 years were receiving corticosteroids at higher doses. Owing to the lack of more precise treatment information, as well as the large number of patients who did not complete the 7-year follow-up visit, drawing conclusions is difficult. While we cannot say, based on these results, that use of certain medication regimens or strategies is more likely to lead to remission, the data at least lend support to the possibility of achieving remission in the long term.
Finally, Ahmad and colleagues performed a post-hoc analysis of the phase 3b AVERT trial of abatacept vs. methotrexate; 172 patients in remission were evaluated at 6 and 12 months after withdrawal of abatacept + methotrexate, abatacept monotherapy, or methotrexate monotherapy. Similar proportions of patients in all three treatment groups experienced a flare (about 58% at 6 months and 66% at 12 months). Patients with higher Health Assessment Questionnaire Disability Index (HAQ-DI) scores and evidence of erosions on MRI at withdrawal were more likely to experience a flare, consistent with prior studies. This highlights potential predictors of withdrawal from therapy. Given the lack of significant difference between the treatment groups, however, it does raise the question of why combination therapy with abatacept and methotrexate is more likely to lead to patients achieving remission in studies without as big an effect on drug-free remission after withdrawal. A more stringent definition of remission rather than DAS-28 C-reactive protein may be desirable.
Vaccination strategies for people with rheumatic diseases have received significant scrutiny in regard to COVID-19 vaccines. People with rheumatoid arthritis (RA) are at higher risk for adverse outcomes related to COVID-19 but also may have reduced immunogenicity to COVID-19 vaccines; thus, temporary withdrawal of medications has been suggested. Renner Araujo and colleagues report the results of a single-center randomized study from Brazil looking at the immune response to two doses of the Sinovac-CoronaVac vaccine in 129 patients with RA. They found that those who stopped methotrexate for 2 weeks after both doses had a higher rate of seroconversion, based on immunoglobulin (Ig) G positivity (78% vs. 54%), than those who remained on methotrexate. Antibody titers were also higher in the "methotrexate-hold" group. Flare rates were higher, based on the Clinical Disease Activity Index (CDAI) — though not on the Disease Activity Scale-28 (DAS-28) — in patients who withdrew from methotrexate. This information is interesting with respect to the use of future inactivated virus vaccines, though its applicability to mRNA vaccines, other than predicting the possibility of flare, is less clear. However, the results could be useful in informed discussions and decision-making regarding withdrawing immunosuppressive drugs.
Some people with rheumatic diseases have been concerned about flares of disease activity related to COVID-19 vaccination. Tedeschi and colleagues conducted a prospective observational study of 71 patients with RA who were previously inoculated against COVID-19 with two mRNA vaccine doses or one adenovirus vector vaccine dose. Using the patient-reported Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5), they measured disease activity weekly from study enrollment through 4 weeks after an additional dose. They did not find any change in mean RADAI-5 score between pre- and post additional dose, nor was disease activity different in patients who stopped disease-modifying antirheumatic drugs (DMARD) compared with those who did not. The study also examined flow cytometry of lymphocyte populations among a subset of these patients (n = 27) and found no significant differences in T peripheral helper cells, T follicular helper cells, age-associated B cells, and plasmablasts among patients before and after the additional vaccine dose. Though the flow cytometry data are difficult to generalize, given the presumed heterogeneity and small number of patients, the lack of change in RA disease activity after the additional vaccine dose is reassuring.
Achievement of remission in patients with RA is also an area of continued interest, especially because of the difficulty of reaching this target under real-world conditions. Larid and colleagues report the prognostic factors of remission and characteristics of 215 patients with RA over 7 years of follow-up at an academic hospital in France. Notably, 33% of patients were in remission at 1 year, of whom 76% remained in remission at 7 years. However, 48% of patients who were not in remission at 1 year achieved remission at 7 years; 58% of study participants were in remission in total at 7 years of follow-up. Those in remission were more frequently being prescribed both conventional synthetic DMARD (csDMARD) and biologic DMARD (bDMARD), while those not in remission at 7 years were receiving corticosteroids at higher doses. Owing to the lack of more precise treatment information, as well as the large number of patients who did not complete the 7-year follow-up visit, drawing conclusions is difficult. While we cannot say, based on these results, that use of certain medication regimens or strategies is more likely to lead to remission, the data at least lend support to the possibility of achieving remission in the long term.
Finally, Ahmad and colleagues performed a post-hoc analysis of the phase 3b AVERT trial of abatacept vs. methotrexate; 172 patients in remission were evaluated at 6 and 12 months after withdrawal of abatacept + methotrexate, abatacept monotherapy, or methotrexate monotherapy. Similar proportions of patients in all three treatment groups experienced a flare (about 58% at 6 months and 66% at 12 months). Patients with higher Health Assessment Questionnaire Disability Index (HAQ-DI) scores and evidence of erosions on MRI at withdrawal were more likely to experience a flare, consistent with prior studies. This highlights potential predictors of withdrawal from therapy. Given the lack of significant difference between the treatment groups, however, it does raise the question of why combination therapy with abatacept and methotrexate is more likely to lead to patients achieving remission in studies without as big an effect on drug-free remission after withdrawal. A more stringent definition of remission rather than DAS-28 C-reactive protein may be desirable.
Vaccination strategies for people with rheumatic diseases have received significant scrutiny in regard to COVID-19 vaccines. People with rheumatoid arthritis (RA) are at higher risk for adverse outcomes related to COVID-19 but also may have reduced immunogenicity to COVID-19 vaccines; thus, temporary withdrawal of medications has been suggested. Renner Araujo and colleagues report the results of a single-center randomized study from Brazil looking at the immune response to two doses of the Sinovac-CoronaVac vaccine in 129 patients with RA. They found that those who stopped methotrexate for 2 weeks after both doses had a higher rate of seroconversion, based on immunoglobulin (Ig) G positivity (78% vs. 54%), than those who remained on methotrexate. Antibody titers were also higher in the "methotrexate-hold" group. Flare rates were higher, based on the Clinical Disease Activity Index (CDAI) — though not on the Disease Activity Scale-28 (DAS-28) — in patients who withdrew from methotrexate. This information is interesting with respect to the use of future inactivated virus vaccines, though its applicability to mRNA vaccines, other than predicting the possibility of flare, is less clear. However, the results could be useful in informed discussions and decision-making regarding withdrawing immunosuppressive drugs.
Some people with rheumatic diseases have been concerned about flares of disease activity related to COVID-19 vaccination. Tedeschi and colleagues conducted a prospective observational study of 71 patients with RA who were previously inoculated against COVID-19 with two mRNA vaccine doses or one adenovirus vector vaccine dose. Using the patient-reported Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5), they measured disease activity weekly from study enrollment through 4 weeks after an additional dose. They did not find any change in mean RADAI-5 score between pre- and post additional dose, nor was disease activity different in patients who stopped disease-modifying antirheumatic drugs (DMARD) compared with those who did not. The study also examined flow cytometry of lymphocyte populations among a subset of these patients (n = 27) and found no significant differences in T peripheral helper cells, T follicular helper cells, age-associated B cells, and plasmablasts among patients before and after the additional vaccine dose. Though the flow cytometry data are difficult to generalize, given the presumed heterogeneity and small number of patients, the lack of change in RA disease activity after the additional vaccine dose is reassuring.
Achievement of remission in patients with RA is also an area of continued interest, especially because of the difficulty of reaching this target under real-world conditions. Larid and colleagues report the prognostic factors of remission and characteristics of 215 patients with RA over 7 years of follow-up at an academic hospital in France. Notably, 33% of patients were in remission at 1 year, of whom 76% remained in remission at 7 years. However, 48% of patients who were not in remission at 1 year achieved remission at 7 years; 58% of study participants were in remission in total at 7 years of follow-up. Those in remission were more frequently being prescribed both conventional synthetic DMARD (csDMARD) and biologic DMARD (bDMARD), while those not in remission at 7 years were receiving corticosteroids at higher doses. Owing to the lack of more precise treatment information, as well as the large number of patients who did not complete the 7-year follow-up visit, drawing conclusions is difficult. While we cannot say, based on these results, that use of certain medication regimens or strategies is more likely to lead to remission, the data at least lend support to the possibility of achieving remission in the long term.
Finally, Ahmad and colleagues performed a post-hoc analysis of the phase 3b AVERT trial of abatacept vs. methotrexate; 172 patients in remission were evaluated at 6 and 12 months after withdrawal of abatacept + methotrexate, abatacept monotherapy, or methotrexate monotherapy. Similar proportions of patients in all three treatment groups experienced a flare (about 58% at 6 months and 66% at 12 months). Patients with higher Health Assessment Questionnaire Disability Index (HAQ-DI) scores and evidence of erosions on MRI at withdrawal were more likely to experience a flare, consistent with prior studies. This highlights potential predictors of withdrawal from therapy. Given the lack of significant difference between the treatment groups, however, it does raise the question of why combination therapy with abatacept and methotrexate is more likely to lead to patients achieving remission in studies without as big an effect on drug-free remission after withdrawal. A more stringent definition of remission rather than DAS-28 C-reactive protein may be desirable.