Different humoral but similar cellular responses of patients with autoimmune inflammatory rheumatic diseases under disease-modifying antirheumatic drugs after COVID-19 vaccination

Abstract

Objectives: The effect of different modes of immunosuppressive therapy in autoimmune inflammatory rheumatic diseases (AIRDs) remains unclear. We investigated the impact of immunosuppressive therapies on humoral and cellular responses after two-dose vaccination.

Methods: Patients with rheumatoid arthritis, axial spondyloarthritis or psoriatic arthritis treated with TNFi, IL-17i (biological disease-modifying antirheumatic drugs, b-DMARDs), Janus-kinase inhibitors (JAKi) (targeted synthetic, ts-DMARD) or methotrexate (MTX) (conventional synthetic DMARD, csDMARD) alone or in combination were included. Almost all patients received mRNA-based vaccine, four patients had a heterologous scheme. Neutralising capacity and levels of IgG against SARS-CoV-2 spike-protein were evaluated together with quantification of activation markers on T-cells and their production of key cytokines 4 weeks after first and second vaccination.

Results: 92 patients were included, median age 50 years, 50% female, 33.7% receiving TNFi, 26.1% IL-17i, 26.1% JAKi (all alone or in combination with MTX), 14.1% received MTX only. Although after first vaccination only 37.8% patients presented neutralising antibodies, the majority (94.5%) developed these after the second vaccination. Patients on IL17i developed the highest titres compared with the other modes of action. Co-administration of MTX led to lower, even if not significant, titres compared with b/tsDMARD monotherapy. Neutralising antibodies correlated well with IgG titres against SARS-CoV-2 spike-protein. T-cell immunity revealed similar frequencies of activated T-cells and cytokine profiles across therapies.

Conclusions: Even after insufficient seroconversion for neutralising antibodies and IgG against SARS-CoV-2 spike-protein in patients with AIRDs on different medications, a second vaccination covered almost all patients regardless of DMARDs therapy, with better outcomes in those on IL-17i. However, no difference of bDMARD/tsDMARD or csDMARD therapy was found on the cellular immune response.

Keywords: Autoimmune Diseases; COVID-19; T-Lymphocyte subsets; Vaccination.

Figure 1

Sample schedule. Schedule of vaccinations and sample collection. The time frame between the first and second vaccination was 3 to 6 weeks for mRNA vaccines or 12 weeks for vector-based vaccination based on the national recommendations. Four weeks after the second SARS-CoV-2 vaccination, all patients were again analysed (‘2nd dose+4 weeks’), following the same procedure as in ‘1st dose+4 weeks’. ‘1st dose’, first vaccination, ‘2nd dose’, second vaccination, ‘1st dose+4 weeks’, 4 weeks after the first vaccination with an mRNA based or vector-based SARS-CoV-2 vaccine, ‘2nd dose+4 weeks’, 4 weeks after the second vaccination with an mRNA vaccine.

Figure 2

Cohort selection. IL, interleukin; i, inhibitor; JAK, Janus-kinase; MTX, methotrexate; TNF, tumour necrosis factor.

Figure 3

Serological immune responses and neutralisation titres against SARS-CoV-2 wild variant in time and by different therapies. Neutralisation titres (ND50) against SARS-CoV-2 in plasma (A) SARS-CoV-2 neutralisation antibodies at ‘2nd dose+4 weeks’ for all four groups of patients on monotherapy (B) Comparison between SARS-CoV-2 neutralisation antibodies at ‘2nd dose+4 weeks’ for all four groups of patients on monotherapy (unfilled plots) and combination therapies (filled coloured plots) (C) Kinetic of SARS-CoV-2 neutralisation antibodies for all four groups of patients on monotherapy with IL17i, TNFi, JAKi and MTX. Serological immune responses against SARS-CoV-2 (D) Spike-specific IgG titres at ‘2nd dose+4 weeks’ for all four groups of patients on monotherapy (E) Comparison between spike-specific IgG titres at ‘2nd dose+4 weeks’ for all four groups of patients on monotherapy (unfilled plots) and combination therapies (filled coloured plots) (F) Correlation of spike-specific IgG titres and SARS-CoV-2 neutralisation antibodies at ‘1st dose+4 weeks’ (G) Correlation of spike-specific IgG titres and SARS-CoV-2 neutralisation antibodies at ‘2nd dose+4 weeks’. The box plots indicate the 75th, 50th and 25th quantile, and the whiskers have a maximum length of 1.5 times the IQR. Each point represents individual values, small triangles represent the additional patients on combination therapy. The following number of patients are presented: IL17i (n=19, ‘1st dose+4 weeks’, n=18, ‘2nd dose+4 weeks’), TNFi (n=27, ‘1st dose+4 weeks’, n=27, ‘2nd dose+4 weeks’), JAKi (n=18 ‘1st dose+4 weeks’, n=18 ‘2nd dose+4 weeks’) and MTX (n=11 ‘1st dose+4 weeks’, n=13 ‘2nd dose+4 weeks’), IL17i/MTX (n=5 ‘2nd dose+4 weeks’), TNFi/MTX (n=4 ‘second dose+4 weeks’), JAKi/MTX (n=6 ‘2nd dose+4 weeks’). ND50, 50% inhibitory dilution; IL, interleukin; TNF, tumour necrosis factor; JAK, Janus-kinase inhibitor; MTX, methotrexate; ρ, Spearman’s correlation coefficient.

Figure 4

Frequencies of activated T cells is similar for all therapy groups. PBMCs were stimulated with peptides spanning the SARS-CoV-2 spike protein and cell activation was evaluated by multiparametric flow cytometry. Activation of CD4⁺ T cells by SARS-CoV-2 S-protein (A) Kinetic of SARS-CoV-2 spike-reactive CD4⁺ T cells, defined by coexpression of CDC154⁺CD137⁺ for all four groups of patients on monotherapy. (B) SARS-CoV-2 spike-reactive CD4⁺ T cells at ‘2nd dose+4 weeks’. (C) Kinetic of ratio of CD3^low expression on activated to non-activated CD4⁺ T cells. (D) Ratio of CD3^low expression on activated to non-activated CD4⁺ T cells at ‘2nd dose+4 weeks’. (E) Kinetic of SARS-CoV-2 spike-reactive CD4⁺ cTfh-like, defined by coexpression of CDC154⁺CD137⁺ on CD4⁺CXCR5⁺ T cells. (F) SARS-CoV-2 spike-reactive CD4⁺ cTfh-like cells at ‘second dose+4 weeks’. Activation of CD8⁺ T cells by SARS-CoV-2 S-protein (G) Kinetic of SARS-CoV-2 spike-reactive CD8⁺ T cells, defined by coexpression of CD137⁺. (H) SARS-CoV-2 spike-reactive CD8⁺ T cells at ‘2nd dose+4 weeks’. Association to final neutralisation capacity (I) Correlation of SARS-CoV-2 spike-reactive CD4⁺ T cells at ‘1st dose+4 weeks’and neutralisation capacity at ‘2nd dose+4 weeks’. (J) Correlation of CD3^low expressing CD4⁺ T cells at ‘2nd dose+4 weeks’ and neutralisation capacity at ‘2nd dose+4 weeks’. The box plots indicate the 75th, 50th and 25th quantile, and the whiskers have a maximum length of 1.5 times the IQR. Each point represents a patient. Gr, granzyme; IL, interleukin; JAK, Janus kinase inhibitor; MTX, methotrexate; PBMCs, peripheral blood mononuclear cells; TNF, tumour necrosis factor; ρ, Spearman’s correlation coefficient.

Figure 5

Frequency of the cytokines IL-2, IFN-γ, TNF and GrB for SARS-CoV-2 spike-reactive CD4⁺ (A) CD8⁺ (B) T cells at ‘2nd dose+4 weeks’. Boolean combinations of assayed cytokines for CD4⁺ and CD8⁺ T cells (C, D). The box plots indicate the 75th, 50th and 25th quantile, and the whiskers have a maximum length of 1.5 times the IQR. Each point represents a patient. Gr, granzyme; IL, interleukin; JAK, Janus kinase inhibitor; MTX, methotrexate; PBMCs, peripheral blood mononuclear cells; TNF, tumour necrosis factor.