Faculty Bibliography

OBJECTIVE:To evaluate seroreactivity and disease flares after COVID-19 vaccination in a multi-ethnic/racial cohort of patients with systemic lupus erythematosus (SLE). METHODS:90 SLE patients and 20 healthy controls receiving a complete COVID-19 vaccine regimen were included. IgG seroreactivity to the SARS-CoV-2 spike receptor-binding domain (RBD) and SARS-CoV-2 microneutralization were used to evaluate B cell responses; IFN-γ production to assess T cell responses was measured by ELISpot. Disease activity was measured by the hybrid SLE disease activity index (SLEDAI) and flares were assigned by the SELENA/SLEDAI flare index. RESULTS:Overall, fully vaccinated SLE patients produced significantly lower IgG antibodies against SARS-CoV-2 spike RBD than controls. Twenty-six SLE patients (28.8%) generated an IgG response below that of the lowest control (<100 units/ml). In logistic regression analyses, the use of any immunosuppressant or prednisone and a normal anti-dsDNA level prior to vaccination associated with decreased vaccine responses. IgG seroreactivity to the SARS-CoV-2 Spike RBD strongly correlated with the SARS-CoV-2 microneutralization titers and antigen-specific IFN-γ production determined by ELISpot. In a subset of patients with poor antibody responses, IFN-γ production was likewise diminished. Pre-/post-vaccination SLEDAI scores were similar. Only 11.4% of patients had a post-vaccination flare; 1.3% were severe. CONCLUSION/CONCLUSIONS:In a multi-ethnic/racial study of SLE patients 29% had a low response to the COVID-19 vaccine which was associated with being on immunosuppression. Reassuringly, disease flares were rare. While minimal protective levels remain unknown, these data suggest protocol development is needed to assess efficacy of booster vaccination.

Background Patients with Systemic Lupus Erythematosus (SLE) represent a unique population at risk for COVID-19 due to underlying immune abnormalities and regular use of immunosuppressant medications. This study was initiated to evaluate for the presence of SARS-CoV-2 IgG antibodies in SLE patients with and without prior COVID-19-related symptoms or COVID-19 RT PCR testing. Methods A total of 329 patients with SLE from two cohorts, one serially monitored for COVID-19 in Spring 2020 (the Web-based Assesment of Autoimmune, Immune-Mediated and Rheumatic Patients (WARCOV) and one undergoing routine surveillance (NYU Lupus Cohort) were tested for SARS-CoV-2 IgG via commercially available immunoassays processed through hospital or outpatient laboratories between April 29, 2020 and February 9, 2021. Results Overall, 16% of 329 patients had a reactive SARSCoV- 2 IgG antibody test. Seropositive patients were more likely to be Hispanic. Other demographic variables, lupus-specific factors and immunosuppressant use were not associated with reactivity. Of the 29 patients with prior RT-PCR confirmed COVID-19, 83% developed an antibody response despite 62% being on immunosuppressants. Six percent of patients who had symptoms suspicious for COVID-19 but negative concurrent RT-PCR testing developed an antibody response. Twenty-three percent of patients who had COVID- 19-related symptoms but no RT-PCR testing and 5% of patients who had no symptoms of COVID-19 developed an antibody response. Among patients initially SARS-CoV-2 IgG positive, the majority maintained reactivity serially. In COVID- 19-confirmed patients high percentages had antibody positivity beyond 30 weeks from disease onset, 88% up to 10 weeks, 83% up to 20 weeks, and 80% up to 30 weeks. Conclusions Most patients with SLE and confirmed COVID- 19 were able to produce a serologic response despite use of a variety of immunosuppressants. These findings provide reassurances regarding the efficacy of humoral immunity and possible reinfection protection in patients with SLE

Background/Purpose: Patients with immune mediated inflammatory disorders (IMIDs) have an inherently heightened susceptibility to infection and may be considered high risk for developing COVID-19. While data regarding the COVID-19 vaccine's immunogenicity in an immunocompetent adult population is rapidly emerging, the ability of IMID patients to adequately respond to these vaccines is not known. Here, we investigate the humoral and cellular immune response to mRNA COVID-19 vaccines in patients with IMIDs on immunomodulatory treatment Methods: Patients with immune mediated inflammatory disorders (IMIDs) have an inherently heightened susceptibility to infection and may be considered high risk for developing COVID-19. While data regarding the COVID-19 vaccine's immunogenicity in an immunocompetent adult population is rapidly emerging, the ability of IMID patients to adequately respond to these vaccines is not known. Here, we investigate the humoral and cellular immune response to mRNA COVID-19 vaccines in patients with IMIDs on immunomodulatory treatment.
Result(s): The NY cohort baseline characteristics are found in Table 1. The Erlangen cohort consisted of 182 healthy subjects, 11 subjects with IMID receiving TNFi monotherapy, and 20 subjects with IMID on MTX monotherapy. In both cohorts, healthy individuals and those with IMID not on MTX were similar in age, while those IMID patients receiving MTX were generally older. In the NY cohort, of the healthy participants, 96.3% demonstrated adequate humoral immune response. Patients with IMID not on MTX achieved a similar rate of high antibody response rate (91.8%), while those on MTX had a lower rate of adequate humoral response (75.0%) (Figure 1A). This remains true even after the exclusion of patients who had evidence of prior COVID-19 infection (P= 0.014). Of note, 3 out of the 4 IMID patients receiving rituximab did not produce an adequate response. Similarly, in the Erlangen validation cohort, 98.3% of healthy controls, 90.9% of patients with IMID receiving TNFi monotherapy, and 50.0% receiving MTX monotherapy achieved adequate immunogenicity (Figure 1B). These differences remain significant when combining the cohorts, using a stricter definition of adequate response, and in a subgroup analysis by age. Cellular response was also analyzed in a subgroup of the NY cohort before and after second vaccination. Activated CD8+ T cells (CD8+ T cells expressing Ki67 and CD38) and the granzyme B-producing subset of these activated CD8+ T cells, were induced in immunocompetent adults and those with IMID not on MTX, but not induced in patients receiving MTX (Figure 2).
Conclusion(s): In two independent cohorts of IMID patients, MTX, a widely used immunomodulator for the treatment of several IMIDs, adversely affected humoral and cellular immune response to COVID-19 mRNA vaccines. Although precise cut offs for immunogenicity that correlate with vaccine efficacy are yet to be established, our findings suggest that different strategies may need to be explored in patients with IMID taking MTX to increase the chances of immunization efficacy against SARS-CoV-2, as has been demonstrated for other viral vaccines

Background/Purpose: Obesity is associated with poor response to treatment in patients with psoriatic arthritis (PsA), however, available data are mostly focused on tumor necrosis factor inhibitor (TNFi) initiators with only a few studies that have examined this association with initiators of other therapies. There are even fewer studies with patient reported outcome (PRO) measures as the outcomes of interest in PsA treatment. The clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA) is a composite measure of disease activity in PsA and the, Routine Assessment of Patient Index Data 3 (RAPID3) and Psoriatic Arthritis Impact of Disease (PsAID) are PROs used in PsA. We examined the association of obesity with change in cDAPSA, RAPID3, PsAID among patients with PsA initiating TNFi, interleukin 17 inhibitors (IL17i) and oral small molecules (OSM).
Method(s): Patients with PsA were enrolled in the Psoriatic Arthritis Research Consortium longitudinal cohort study in the US between 2016-2020, initiated therapy with either TNFi, IL17i or OSM and completed at least one follow up visit. Treatment response was assessed by change in cDAPSA, RAPID3, or PsAID. Patients were stratified based on body mass index category (normal weight = BMI 19 to < 25 kg/m², overweight = BMI 25 to < 30 kg/m², obese = BMI >= 30 kg/m²). Baseline characteristics were reported descriptively. BMI category and its association with change in the outcomes of interest was examined in univariable and age-and-sex adjusted linear regression models.
Result(s): A total of 310 patients were included in the analysis. The mean age of patients was 52 and 56% were female. At baseline, the mean cDAPSA was 17.3 (SD 12.7), the mean PsAID was 3.6 (SD 2.2), the mean RAPID3 was 10.9 (SD 5.8). Baseline scores were overall similar when stratified by BMI category (Table 1). The mean change in cDAPSA was lowest among obese patients (-2.91 (SD 9.56) in normal BMI, -2.29 (SD 11.48) in overweight BMI, and -1.42 (SD 12.33) in obese BMI). The mean change in RAPID3 was lowest among obese patients (-1.53 (SD 4.50) in normal BMI, -1.69 (SD 4.47) in overweight BMI, and -0.26 (SD 5.46) in obese BMI). The mean change in PsAID was lowest among obese patients (-0.58 (SD 1.48) in normal weight BMI, -0.72 (SD 1.47) in overweight BMI, and -0.17 (SD 1.98) in obese BMI) (Figure 1). These differences were not statistically significant, potentially due to sample size. In unadjusted and age-and-sex adjusted analyses (Table 2), compared to the normal BMI category, obese patients had less improvement in cDAPSA, RAPID3 and PsAID. Similar numerical reduction in improvement was also found in the TNFi initiators although there was not a stepwise decrease in improvement with increasing BMI in IL17i nor OSM initiators.
Conclusion(s): The mean change in the selected outcome measures (cDAPSA, RAPID3, PsAID) was lowest among obese patients compared to the other BMI categories. Interestingly, this pattern was observed primarily among TNFi initiators as opposed to OSM or IL17i initiators (Figure Presented)

Background/Purpose: Psoriasis (PsO) is an inflammatory, immune-mediated skin disorder affecting ~3% of the population worldwide. It is associated with multiple comorbidities, including psoriatic arthritis (PsA), which occurs in up to a third of patients. While genes contribute to the pathogenesis of psoriatic disease, twin studies demonstrate substantial discordance in PsO and PsA, suggesting that epigenetics and environmental factors play a significant role. In fact, there is increasing evidence that the microbiome has an impact on psoriatic disease pathogenesis. However, prior investigations were performed in populations of unrelated individuals and could not discern environmental from genetic influences. To characterize the host-microbiome relationship, we studied the gut and skin microbiome of monozygotic (MZ) twins discordant for psoriatic disease in order to determine disease-specific microbial perturbations that are independent of host-genes.
Method(s): Stool and skin swabs were collected from subjects with psoriatic disease and their unaffected MZ twin siblings (pairs=9, n=18). Non-lesional (NL) or healthy skin was swabbed at three separate sites: bicep, scalp, and elbow/forearm. Fecal samples underwent shotgun metagenomic sequencing to deeply characterize the gut microbiome taxonomy and functional pathways at high resolution. Sequences were processed with the HUMAnN and MetaPhlAn2 pipelines. Skin swab samples underwent 16S rRNA sequencing to characterize the cutaneous bacterial microbiome. Forward sequences were processed with the QIIME2 pipeline and SILVA reference database. Downstream computational analysis was performed using several libraries in R, including DESeq2.
Result(s): In gut samples, the relative abundance of Ruminococcus bromii species was significantly reduced and two pathways related to tetrahydrofolate biosynthesis were upregulated in psoriatic twins compared to their corresponding unaffected siblings (Fig 1; p< 0.05, Mann-Whitney). In NL skin samples from psoriatic twins, there was a significant reduction in alpha diversity and beta diversity differences in microbial communities of the scalp, but not the bicep or elbow/forearm, compared to healthy samples from unaffected twins (Fig 2A-B; p< 0.05, Mann-Whitney and Permanova). Differential analysis of taxa in the scalp identified a higher abundance of the Bacillales order and related taxa, as well as a lower abundance of the Deinococcus genus and related taxa in psoriatic twins compared to their unaffected siblings (Fig 2C; p< 0.05 with FDR correction).
Conclusion(s): This is the first study exploring microbial differences in MZ twins discordant for psoriatic disease. In agreement with our previous results, we found that Ruminococcus is reduced or virtually absent in the gut of psoriatic patients, and may therefore be associated with psoriatic disease. Additionally, we discovered that even healthyappearing NL skin of psoriatic subjects, particularly in the scalp, exhibited microbial perturbations and decreased diversity compared to unaffected twins. A further understanding of these changes and their downstream effects should shed light into the pathogenesis of psoriatic disease beyond genetic susceptibility

The coronavirus disease 2019 (COVID-19; caused by SARS-CoV-2) pandemic has affected the healthcare system on a global scale, and we utilized the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2020 annual meeting to examine how COVID-19 might affect patients with psoriatic disease (PsD) and the clinicians who care for them. Pressing issues and concerns identified included whether having psoriasis increased the risk of acquiring COVID-19, vaccine safety, and the acceptability of telehealth. The general message from rheumatologists, dermatologists, infectious disease specialists, and patient research partners was that data did not suggest that having PsD or its treatment significantly increased risk of infection or more severe disease course, and that the telehealth experience was a success overall.