Anti-TNF therapy impairs both short- and long-term IgG responses after repeated vaccination

Abstract

Background: Recently, it has been questioned whether vaccination of patients with inflammatory (auto)immune diseases under anti-tumor necrosis factor (TNF) treatment leads to impaired vaccine-induced immune responses and protection against breakthrough infections. However, the effects of TNF blockade on short- and long-term immune responses after repeated vaccination remain unclear. Vaccination studies have shown that initial short-term IgG antibodies (Abs) carry highly galactosylated and sialylated Fc glycans, whilst long-term IgG Abs have low levels of galactosylation and sialylation and are most likely generated by long-lived plasma cells (PCs) derived primarily from the germinal center (GC) response. Thus, IgG Fc glycosylation patterns may be applicable to distinguish short- and long-term vaccine responses after repeated vaccination under the influence of anti-TNF treatment.

Methods: We used COVID-19 vaccination as a model to investigate vaccine-induced IgG subclass levels and Fc glycosylation patterns, B cell subsets, and effector functions of short- and long-term Ab responses after up to three vaccinations in patients on anti-TNF or other immunosuppressive treatments and in healthy individuals. Using TriNetX, a global healthcare database, we determined the risk of SARS-CoV-2 breakthrough infections in vaccinated patients treated with anti-TNF or other immunosuppressive drugs.

Results: Anti-TNF treatment reduced the long-term abundance of all anti-S IgG subclasses with low levels of galactosylation and sialylation. Re-activation of potential memory B cells initially generated highly galactosylated and sialylated IgG antibodies, which were progressively reduced after each booster dose in anti-TNF-treated patients, especially in the elderly. The reduced short- and long-term IgG (1) levels in anti-TNF-treated patients correlated with diminished functional activity and an increased risk for the development of COVID-19.

Conclusions: The data suggest that anti-TNF treatment reduces both GC-dependent long-lived PCs and GC-dependent memory B cell-derived short-lived PCs, hence both the long- and short-term IgG subclass responses, respectively, after repeated vaccination. We propose that anti-TNF therapy, especially in the elderly, reduces the benefit of booster vaccination.

Keywords: COVID‐19; IgG; IgG glycosylation; IgG4; SARS‐CoV‐2; TriNetX; antibody; anti‐TNF treatment; germinal center; inflammatory diseases; long‐lived plasma cell; mRNA vaccine; memory B cell; short‐lived plasma cell; vaccination.

FIGURE 1

Anti‐S(1) serum IgG subclass and IgA levels in anti‐TNF‐treated vaccinees. (A) Cohort description (created with biorender.com). (B) Vaccination‐induced anti‐S1 serum IgG1‐4 and IgA levels detected by ELISA of the three groups indicated. Four different time points were analyzed: (i) shortly (3–5 weeks) post first, (ii) shortly (1 week) post second, (iii) long (6 months) post second, and (iv) shortly (1 week) post third mRNA vaccination. Dashed lines: Anti‐S1 IgG subclass levels of unvaccinated healthy (negative) controls. (C) Summed anti‐S serum glycopeptide intensities of the IgG subclasses as detected by LC–MS (IgG2 and IgG3 glycopeptides were not distinguished by our method). Dotted line: Cut‐off threshold. Statistics: Kruskal‐Wallis test for each time point, *p < .05, **p < .01, ***p < .001, ****p < .0001.

FIGURE 2

Anti‐S(1) serum IgG subclass and IgA levels in anti‐TNF‐treated vaccinees stratified by age. Summed anti‐S serum IgG subclass glycopeptide intensities as detected by LC–MS and anti‐S1 IgA levels detected by ELISA shortly (1 week) post second and long (6 months) post second mRNA vaccination of the three groups are shown. Antibody levels were plotted against age and two different age groups were additionally examined: (i) 24–39 years and (ii) 40–57 years, indicated by the vertical dashed lines. Dotted line: Cut‐off threshold. Statistics: Kruskal–Wallis test for the 40–57 years subgroup or total group as indicated, *p < .05, **p < .01, ***p < .001, ****p < .0001. The first value compares the healthy group with the anti‐TNF‐treated group; the second value compares the other DMARD‐treated group with the anti‐TNF‐treated group. Colored lines indicate simple linear regression.

FIGURE 3

Glycosylation patterns of the anti‐S IgG subclasses in anti‐TNF‐treated vaccinees. (A) The six major IgG Fc N‐glycans attached to Asn 297 of IgG1: Galactose: G, yellow circle; sialic acid: S, purple diamond; fucose: F, red triangle; mannose: Green circle; N‐acetylglucosamine: GlcNAc and bisecting GlcNAc: N, blue square. (B) Anti‐S serum IgG subclass Fc glycosylation patterns: Fucosylation, bisection, galactosylation, and sialylation shortly post second and long post second vaccination of the indicated three groups. Statistics: Kruskal–Wallis test for each time point, *p < .05, **p < .01, ***p < .001, ****p < .0001.

FIGURE 4

Functional activity of anti‐S antibodies from anti‐TNF‐treated vaccinees. (A–D) Sera shortly (1 week) post second or long (6 months) post second vaccination of the three indicated groups were analyzed for their potential to activate cellular or complement assays: (A) antibody‐dependent neutrophil phagocytosis (ADNP), (B) antibody‐dependent cellular phagocytosis (ADCP), (C) antibody‐dependent complement deposition (ADCD), and (D) antibody‐dependent natural killer cell activation with three readouts (ADNKA‐CD107⁺/IFNy⁺/MIP‐1b⁺). (E–H) The functional data were normalized to the anti‐S IgG (IgG1 + IgG2/3 + IgG4) summed intensities analyzed by LC–MS. Statistics: Kruskal–Wallis test for each time point, *p < .05, **p < .01, ***p < .001, ****p < .0001.

FIGURE 5

S1‐specific memory B cells. (A) S1‐specific total, IgG⁺ (IgM‐IgA‐IgD‐), IgM⁺, and IgA⁺ memory B cells (CD19⁺ CD20⁺ CD27⁺), which were identified by flow cytometry as cells/ μL blood shortly post second vaccination of the indicated groups. Statistics: Kruskal–Wallis test, *p < .05. (B) IgG⁺ and IgA⁺ S1‐specific memory B cells shortly post second vaccination were correlated with anti‐S1 IgG1‐4 (ratio to reference values) or IgA (U/mL) levels, respectively, shortly post 2nd vaccination. Statistics: Spearman correlation, respective r‐ and p‐values are shown.

FIGURE 6

IgG subclass glycosylation patterns after re‐activation of potential (GC‐derived) IgG subclass⁺ memory B cells shortly post third vaccination. (A) Cohort description. (B) Anti‐S1 IgG subclass levels identified by ELISA, (C) anti‐S summed glycopeptide intensities of the IgG subclasses as detected by LC–MS, and (D) anti‐S IgG subclass glycosylation before and shortly post third vaccination. Statistics: Mann–Whitney tests for the individual IgG subclasses, ***p < .001, ****p < .0001.

FIGURE 7

Meta‐analysis of COVID‐19 cases in patients with inflammatory (auto)immune diseases. Increased risk of developing COVID‐19 observed in patients with inflammatory (auto)immune diseases treated with TNF inhibitors versus those receiving α4β7 integrin inhibitors or MTX (other DMARDs). Line thickness represents the 95% confidence interval. Kaplan–Meier curves were compared using the log‐rank test; p = .0027.