Use of TNFi Therapy in Psoriatic Arthritis and COVID-19 Vaccine Immunogenicity: Is There a Link?

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Researchers studied the immune response to COVID-19 vaccination in patients with psoriatic arthritis receiving treatment with tumor necrosis factor inhibitors.

Compared with healthy control participants, patients with psoriatic arthritis (PsA) receiving treatment with tumor necrosis factor inhibitors (TNFis) did not show a reduced immune response to the BNT162b2 COVID-19 vaccine, according to study results in RMD Open.

Phase 3 trials of messenger RNA (mRNA) COVID-19 vaccines have historically excluded patients receiving immunosuppressive medications; therefore, the immunogenicity of mRNA vaccines in patients with rheumatic diseases and the association with disease-modifying antirheumatic drug (DMARD) therapy during COVID-19 vaccination has not been clear.

The aim of the current study was to evaluate the immune response to COVID-19 vaccination in patients with PsA receiving TNFi therapy compared with healthy control participants.

Patients with PsA receiving treatment with TNFis received 2 shots of the BNT162b2 mRNA SARS-CoV-2 vaccine (Pfizer-BioNTech) 3 weeks apart. Serum immunoglobulin (Ig) G levels against SARS-CoV-2 were assayed 15 days after the second shot. Treatment with TNFis was continued during the study period. However, among patients receiving combination therapy, methotrexate was discontinued for 1 week after each vaccine dose, according to guidance from the American College of Rheumatology (ACR).

Demographic and clinical characteristics, including disease severity and COVID-19 history/current symptoms, were recorded at baseline and at the time of serum IgG testing. Serum IgG was also measured in the control group 15 days after the second Pfizer-BioNTech COVID-19 vaccine. Differences in immunogenicity between patients and control participants were analyzed using student’s t-test and logistic regression.

A total of 40 patients with PsA (mean age, 52.85±10.41 years; 55% women; mean disease duration, 11±9.0 years) receiving TNFi therapy during COVID-19 vaccination were enrolled in the study.

Researchers noted that PsA disease activity remained consistent before and after vaccination (P =.92). Patients with PsA showed a positive immune response that was lower, but not significantly different, than that of the immune response of the control participants (P =.08).

Methotrexate use among study participants was not associated with lower anti-SARS-CoV-2 IgG levels (P =.07), while glucocorticoid use predicted lower immunogenicity (P =.04).

Limitations of the study included the small sample size and the possibility that patients may have developed asymptomatic SARS-CoV-2 infection before vaccination.

The researchers concluded, “Continuing TNFi therapy in patients with PsA throughout the vaccination period was not associated with hampered immune response and it was safe. Although [methotrexate] was not associated with decreased IgG titers, more data are needed to clarify whether holding [methotrexate] after vaccination may lead to optimal immunogenicity.”


Venerito V, Stefanizzi P, Fornaro M, et al. Immunogenicity of BNT162b2 mRNA SARS-CoV-2 vaccine in patients with psoriatic arthritis on TNF inhibitors. RMD Open. Published online January 5, 2022. doi:10.1136/rmdopen-2021-001847