The Effect of tumor necrosis factor blockade on the response to pneumococcal vaccination in patients with rheumatoid arthritis and ankylosing spondylitis

https://doi.org/10.1053/j.semarthrit.2003.10.003Get rights and content

Abstract

Objective

To assess the effect of anti-tumor necrosis factor (TNF) α therapies on the immunogenicity of pneumococcal vaccination in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

Methods

A group of 16 consecutive patients (11 with RA and 5 with AS) treated either with infliximab or etanercept, and a control group of 17 age-matched RA patients treated with disease-modifying medications other than anti-TNF-α, received intradeltoid injection with 0.5 mL of pneumococcal vaccine. Pneumococcal polysaccharide (PPS)-specific IgG to 7 vaccine PPS (representing high- and low-prevalence serotypes) was measured by enzyme-linked immunosorbent assay in sera obtained before and 1 month after pneumococcal immunization.

Results

One month after vaccination, both groups had significant increases in the geometric mean concentration of capsule PPS-specific antibody and in the mean fold increase in antibody levels to all 7 serotypes, compared with prevaccination levels. However, compared with the control group, the TNF-α blockade-treated patients tended to have lower antibody increases for all the serotypes tested except serotype 14. In addition, lower proportions of TNF-α blockade-treated patients responded to pneumococcal vaccination compared with patients on other therapies. Similarly, more TNF-α blockade-treated patients were poor responders compared with patients not on anti-TNF-α treatment.

Conclusion

Treatment of groups of patients with etanercept or infliximab does not impair their mean antibody responses to pneumococcal vaccination. However, a larger proportion of RA patients may not respond adequately to pneumococcal vaccination once on TNF-α blockade therapies. Consequently, pneumococcal vaccination before starting TNF-α blockade therapy is recommended.

Section snippets

Subjects

The study group included 11 consecutive patients who fulfilled the American College of Rheumatology criteria for RA (13) and 5 patients who fulfilled the New York Clinical criteria for AS. All patients were treated with TNF-α blockade: either intravenous infliximab at a dosage of 3 mg/kg at week 0, week 2, week 6, and every 8 weeks thereafter, or subcutaneous etanercept 25 mg, twice a week. Because age plays an important role in the response to pneumococcal vaccine (14), the control group

Characteristics of patients and control subjects

The TNF-α blockade-treated patients and the control group did not differ significantly by age, gender, duration of disease, or in use of nonsteroidal anti-inflammatory drugs (NSAIDs) or methotrexate (MTX) (Table 1). Both groups were predominantly female, and approximately 30% of patients were receiving NSAIDs and 60% to 65% were receiving MTX. Significantly more patients in the control group were treated with prednisone, or using doses >10 mg/d, compared with the TNF-α blockade-treated

Discussion

In this study, we have shown that pneumococcal vaccination, using the commercial 23-valent pneumococcal polysaccharide vaccine, can induce statistically significant humoral responses despite treatment with TNF-α blockade therapies. Our data are in agreement with a preliminary report suggesting that treatment with etanercept does not interfere with mean immune responses to pneumococcal vaccination in patients with psoriatic arthritis (19). However, a smaller percentage of the TNF-α

Ori Elkayam, MD: Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

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  • Cited by (0)

    Ori Elkayam, MD: Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

    Dan Caspi, MD: Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

    Tatiana Reitblatt, MD: Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

    Darlene Charboneau: Pulmonary Division, Minneapolis VA Medical Center, Minneapolis, Minnesota

    Jeffrey B. Rubins, MD: Pulmonary Division, Minneapolis VA Medical Center, Minneapolis, Minnesota

    Supported by National Institutes of Health Grant IH AI02440 (to J.B.R.).

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