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Jena A, Mishra S, Deepak P, et al. Response to SARS-CoV-2 vaccination in immune mediated inflammatory diseases: Systematic review and meta-analysis. Autoimmun Rev. 2021 Aug 30:102927. doi: 10.1016/j.autrev.2021.102927. (Systematic review)
Abstract

OBJECTIVES: The treatment for COVID-19 often utilizes immune-modulating drugs. These drugs are also used in immune mediated inflammatory diseases (IMIDs). We performed a systematic review about seroconversion after SARS-CoV-2 vaccination in patients with IMIDs and impact of various drugs on seroconversion rates.

METHODS: Electronic databases were searched to identify relevant studies reporting seroconversion rates following SARS-CoV-2 vaccination in IMIDs. We calculated the pooled seroconversion rates after a single or two doses of vaccination, pooled seroconversion rates in patients with specific IMIDs, and rates in patients on various drugs/drug classes.

RESULTS: Twenty-five studies were included in the systematic review. The pooled seroconversion rates after two doses of mRNA vaccination were higher (83.1, 95%CI: 74.9-89.0, I2 = 90%) as compared to a single dose (69.3, 52.4-82.3, I2 = 95%). The odds of seroconversion were lower in IMIDs as compared to healthy controls (0.05, 0.02-0.13, I2 = 21%). The seroconversion rates in patients with inflammatory bowel disease (95.2, 95%CI: 92.6-96.9, I2 = 0%), spondyloarthropathy (95.6, 95% CI: 83.4-98.9, I2 = 35%), and systemic lupus erythematosus (90.7, 95%CI: 85.4-94.2, I2 = 0%) were higher as compared to rheumatoid arthritis (79.5, 95% CI: 65.1-88.9, I2 = 85%), and vasculitis (70.5, 95% CI: 52.9-83.5, I2 = 51%). The seroconversion rates following double dose of mRNA were excellent (>90%) in those on anti-tumour necrosis factor (TNF), anti-integrin (vedolizumab), anti-IL 17 (secukinumab), anti-IL6 (Tocilizumab) and anti-IL12/23 (Ustekinumab) therapies but attenuated (<70%) in patients on anti-CD20 (Rituximab) or anti-cytotoxic T lymphocyte associated antigen (CTLA-4) therapies (Abatacept). The seroconversion rates were good (70-90%) with steroids, hydroxychloroquine, JAK inhibitors, mycophenolate mofetil and leflunomide. Combination of anti-TNF with immunomodulators (azathioprine, 6-meracptopurine, methotrexate) resulted in an attenuated vaccine response as compared to anti-TNF monotherapy.

CONCLUSION: Seroconversion rates after SARS-CoV-2 vaccination are lower in patients with IMIDs. Certain therapies (anti-TNF, anti-integrin, anti-IL 17, anti-IL6, anti-12/23) do not impact seroconversion rates while others (anti-CD20, anti-CTLA-4) result in poorer responses.

Ratings
Discipline Area Score
Public Health 7 / 7
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Internal Medicine 6 / 7
Gastroenterology 6 / 7
Rheumatology 6 / 7
Comments from MORE raters

Family Medicine (FM)/General Practice (GP) rater

In family medicine, we have many of calls/questions about patients who are on medications for IMID. This article will help public health determine criteria for possible repeat vaccination.

Gastroenterology rater

This meta-analysis of 25 individual studies quantifies the response to vaccination against SARS-CoV-2 in patients with immune-mediated diseases under treatment with various immunosuppressive drugs, alone or in combination. The heterogeneity of the different meta-analyzes, reduced once the studies with patients treated with the same drugs were combined, increases confidence in the results. This work will help to optimize vaccination results by modifying vaccine uses according to the type of vaccine (mRNA or adenovirus vector), number of doses, immunomodulatory/immunosuppressive therapy being administered or type of immune-mediated disease. Despite an increased response to the vaccine among patients with inflammatory bowel disease, spondyloarthropathy and systemic lupus erythematosus as compared to rheumatoid arthritis and vasculitis were documented, the likely younger age of the former could explain these results, but this aspect was not specifically investigated.

Public Health rater

This timely review provides useful information for counseling patients with immune-related disease and assesses the effect of ongoing immunosuppressive therapy on response to COVID-19 vaccination. There is yet a need for a study of the practice by some clinicians of stopping immunomodulators before COVID-19 vaccination.

Rheumatology rater

This is outstanding summary of current data concerning COVID-19 vaccination in patients with rheumatic disease treated with a variety of medications. While the numbers remain on the small side, this information can be used to directly assist in clinical decision making regarding vaccination for COVID-19.
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