MTX withdrawal after COVID-19 vaccination improves immunogenicity in RA patients but at a cost

Brazil: Data from a recent study revealed that 2-week methotrexate (MTX) discontinuation after each dose of the Sinovac-CoronaVac vaccine improves anti-SARS-CoV-2 immunogenicity in patients with rheumatoid arthritis (RA). The strategy, however, was associated with higher flare rates following the second dose of the vaccine and may be attributed to the short-term interval between vaccine doses. The study appears in the BMJ journal Annals of the Rheumatic Diseases. 

It is known that in rheumatoid arthritis patients, temporary MTX withdrawal for 2 weeks following the influenza vaccine improves immunogenicity without worsening disease activity.

Considering the above, Eloisa Bonfa, Rheumatology Division, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Brazil, and colleagues aimed to evaluate the effect on immunogenicity and safety of 2-week MTX discontinuation after each dose of the Sinovac-CoronaVac vaccine versus MTX maintenance in RA patients in a single-center, prospective, randomized, investigator-blinded, intervention study. 

The study included adult patients with RA (stable Clinical Disease Activity Index (CDAI) ≤10, prednisone ≤7.5 mg/day). They were randomized in a ratio of 1:1 to withdraw MTX (MTX-hold) for 2 weeks after each vaccine dose or maintain MTX (MTX-maintain), evaluated at day 0 (D0), D28, and D69. 

Anti-SARS-CoV-2 S1/S2 IgG seroconversion (SC) and neutralising antibody (NAb) positivity at D69 were the coprimary outcomes. Secondary outcomes were geometric mean titres (GMT) and flare rates. Patients with baseline positive IgG/NAb were excluded for immunogenicity analyses, and for safety reasons those who flared at D28 (CDAI >10) and did not withdraw MTX twice.

Randomisation included 138 patients with 9 exclusions (5 COVID-19, 4 protocol violations). 

The researchers conclude, this study provides novel data that 2-week MTX withdrawal after each vaccine dose improves anti-SARS-CoV-2 IgG response to the Sinovac-CoronaVac vaccine.

"The increased flare rates following the second MTX withdrawal may be due to the short-term interval between vaccine doses," the authors wrote. "This strategy requires close surveillance and shared decision making due to the possibility of disease activity worsening."

Reference:

Araujo CSR, Medeiros-Ribeiro AC, Saad CGS, et alTwo-week methotrexate discontinuation in patients with rheumatoid arthritis vaccinated with inactivated SARS-CoV-2 vaccine: a randomised clinical trialAnnals of the Rheumatic Diseases Published Online First: 22 February 2022. doi: 10.1136/annrheumdis-2021-221916