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Abstract
Background The risk of COVID-19 infection is increased in patients with systemic lupus erythematosus (SLE), and immunosuppressive medications including corticosteroids impact the risk. Furthermore, immunosuppressive medications may reduce the effectiveness of COVID-19 vaccination. Consensus documents have suggested management strategies on handling immunosuppressive medications to increase vaccine efficacy, but the benefit of such strategies has not been proven.
Methods We collected information on COVID infection, COVID vaccination history, and COVID antibodies in the Hopkins Lupus Cohort, a longitudinal cohort with structured quarterly visits. A cohort of healthcare workers was used for comparison. SARS-CoV-2 IgG was measured by ELISA (Euroimmun). Outcome measures included: SARS-CoV-2 antibody IgG levels after vaccination over time in both cohorts; and effect of immunosuppressive medications on post-vaccine IgG levels in SLE patients.
Results 228 SLE patients received COVID-19 vaccine: 10 had 1 dose of Johnson & Johnson; 94 had 2 doses of Moderna; and 124 had 2 doses of Pfizer. Of these, 98 patients had no history of COVID infection and at least 1 visit within 210 days before the vaccine series and at least one visit after the vaccine series. SLE patients on immunosuppressive medications had lower post-vaccine IgG levels than SLE patients who were not; but both groups had lower levels than healthcare workers (figure 1). Holding mycophenolate for one week after vaccine increased post-vaccine IgG levels significantly. In multiple variable models, mycophenolate mofetil, tacrolimus, and belimumab all significantly reduced antibody response to vaccination (table 1).
Conclusion SLE patients, regardless of background immunosuppressive therapy, had lower vaccine IgG levels than healthcare workers. Belimumab, tacrolimus and mycophenolate use significantly reduced IgG response to vaccine. Holding mycophenolate for one week improved vaccine efficacy, providing clinical benefit on vaccine response, without leading to clinical flares.
Mean antibody level by time since the second vaccination for each cohort. Estimated mean IgG measure over time since 2nd vaccination, by cohort and use of immunosuppressants (IS).
Estimated effect of treatment at time of vaccination on mean IgG based on a multivariable regression model
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