Patients With Autoimmune Disease May Not Be Fully Protected Even After Second COVID Shot

By Megan Brooks

May 25, 2021

NEW YORK (Reuters Health) - Patients with rheumatic and musculoskeletal diseases who are on immunosuppressants may not mount a response to the SARS-CoV-2 messenger RNA vaccine, even after the second dose, and patients on B-cell modulating agents and mycophenolate appear particularly vulnerable.

"While additional research is required, patients on immunosuppressants should be aware that they may not be fully protected against COVID even after full vaccination. Therefore, patients should talk to their providers before relaxing precautions," Dr. Julie Paik of Johns Hopkins University School of Medicine, in Baltimore, Maryland, told Reuters Health by email.

Dr. Paik and colleagues analyzed clinical characteristics of 20 patients with rheumatic and musculoskeletal diseases who did not have detectable antibodies against the receptor-binding domain (RBD) of the SARS-CoV-2 spike protein at a median of 30 days after receiving the second dose of SARS-CoV-2 mRNA vaccine. The cohort was made up of mostly white women; the median age was 46 years.

Twelve patients (60%) received the Pfizer-BioNTech and eight (40%) received the Moderna mRNA vaccine series, the researchers report in Annals of Internal Medicine.

The most common diagnosis was systemic lupus erythematosus (50%), followed by myositis (25%) and vasculitis (15%). One patient had Sjogren syndrome and one had sarcoidosis.

Most patients were on multiple immunosuppressive agents (90%); 16 patients (80%) were on maintenance corticosteroids, with a median dose of 5 mg (range, 2.5 to 55 mg).

Rituximab (55%) was the most commonly used biologic agent and mycophenolate (50%) was the most commonly used disease-modifying antirheumatic drug.

"A unifying factor among patients in this case series was the use of either a B-lymphocyte-depleting agent or medication that affects lymphocytes. This supports the critical role of B-cell immunocompetence in generating appropriate response to vaccine antigen," Dr. Paik and colleagues say.

"Of note, participants reported rituximab infusion at a median of 14 weeks before the first vaccine dose. Rituximab has been associated with worse outcomes in patients with rheumatic and musculoskeletal diseases and SARS-CoV-2 infection and thus it is of further concern that these patients may not derive protection from vaccination," they say.

Dr. Paik noted that they measured response to the SARS-COV-2 mRNA vaccine by looking for anti-RBD. "While additional research is needed to determine whether this antibody test is a definitive surrogate of neutralizing antibodies, we believe that our study highlights the need for physicians and patients to be aware that immunosuppressants may prevent an appropriate vaccine response against SARS-CoV-2," she said.

SOURCE: Annals of Internal Medicine, online May 24, 2021.