key: cord-0695228-apca4oxi authors: Auteri, Giuseppe; Bartoletti, Daniela; Di Pietro, Christian; Sutto, Emanuele; Mazzoni, Camilla; Romagnoli, Andrea Davide; Vianelli, Nicola; Lazzarotto, Tiziana; Cavo, Michele; Palandri, Francesca title: Longer-term response to SARS-CoV-2 vaccine in MPN patients: role of ruxolitinib and disease severity. date: 2022-03-03 journal: Leuk Res DOI: 10.1016/j.leukres.2022.106819 sha: 197679dbcd9722eaa6f21c55caafc7c36640e13f doc_id: 695228 cord_uid: apca4oxi nan Patients with Philadelphia-negative chronic myeloproliferative neoplasms (MPNs) are at higher risk of acquiring the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and have a poor outcome after infection, with a mortality rate of about 30%, increasing to 48% in patients with Myelofibrosis (MF) [1, 2] . COVID-19 vaccines have been readily and highly recommended in hematological patients [3] [4] [5] . In Italy, the BNT162b2 (Pfizer-BioNTech) mRNA vaccine was particularly recommended in frail individuals. MPN patients may have lower responses to vaccines due to reduced immunological competence that is related to both the hematological disease and the immunosuppressive and/or myelotoxic effects of the treatments [6, 7] . Table 1 summarizes previous reports on serological J o u r n a l P r e -p r o o f response in MPN patients [8] [9] [10] [11] [12] [13] . Also, in a recent systematic review, the rate of seroconversion after SARS-CoV-2 vaccine was 78% in the MPN cohort [14] . To capture the humoral response over time, serologic tests for SARS-CoV-2 antibodies (Ab) were performed according to routine practice in 58 consecutive MPN patients after at least 5 weeks from the second dose of the BNT162b2 vaccine referred for hematologic examination during the period from April to May 2021 (Figure 1) . Concurrently, qualitative anti-N antibody analysis was performed to exclude patients who had asymptomatic infection before serologic evaluation. The test quantified the IgG Ab titers against the anti-S receptor binding domain (RBD) by electro-chemiluminescence. The Elecsys® Anti-SARS-CoV-2 ECLIA assay (Roche Diagnostics AG, Rotkreuz, Switzerland) performed on the cobas e 801 analyzer (Roche Diagnostics) was used. The assay uses recombinant proteins representing the SARS-CoV-2 spike (S) protein receptor binding domain (RBD) in a double-antigen sandwich assay format, which favors detection of late, mature and high affinity antibodies against SARS-CoV-2. The dosage units (U/mL) of the Elecsys assay are considered equal to the units of the WHO international standard (BAU/mL) for anti-SARS-CoV-2 S (RBD) antibodies. The conversion factor is 1. Anti-S (RBD) were negative if <0.8 BAU/mL, inconclusive if ≥0.8 to <5 BAU/mL and positive if ≥5 BAU/mL. Patients above this upper cut-off level were considered responders. To further characterize this cohort, patients with Ab titers within the first quartile (<60 BAU/mL) were defined "no/poorer -responders" while patients with Ab titer values within the last quartile (>830 BAU/mL) were defined as "better responders". Comparisons of quantitative variables between groups of patients were carried out by Wilcoxon-Mann-Whitney rank-sum test or by Kruskal-Wallis and Dann test, as appropriate, while associations between categorical variables were tested by the χ2 test. Variables significantly associated to antibody titers in univariate analysis were considered in the multivariable analysis (MVA), carried out using a logistic regression model. Notably, 46% of patients experienced localized inflammation and 13.8% of patients had transitory fatigue/headache/malaise after vaccine inoculation. After a median of 15.4 weeks after serological evaluation (range, 9.6 -17) , no SARS-CoV-2 infection, no thrombotic events and no long-term vaccine-related adverse events have been documented among vaccinated patients. Clinical and laboratory characteristics of the study cohort are summarized in Supplemental Table 1 . Median time from second vaccine inoculation and serological evaluation was 10.6 weeks (range, 5.8-15). Median Ab titers in the cohorts that were evaluated after 5-10 or 10-11 or 11-15 weeks were comparable (519, 140, 214, respectively, p=0.06). Median time from vaccine to serological test was comparable across hematological neoplasms (10.1, 10 and 11 weeks in ET, PV, and MF patients, respectively, p=0.11) and between RUX-treated (10.2 weeks) and RUX-untreated (10.6 weeks) patients (p=0.49). In 6 patients, Ab anti-N were identified, indicating a previous asymptomatic contact with SARS-CoV-2. Among the remaining 52 patients, 13 had ET, 23 PV and 16 MF (5 Primary). Median Ab titer was 279.5 BAU/mL (range 0.6 ->2500). Median antibody titer was significantly associated to the type of MPN (Supplemental Figure 1) . It was lower in MF (median antibody titer: 51.4 BAU/mL, range 0.6 -529) compared to PV (median, 274 BAU/mL, range 1.7 ->2500, p<0.001) and ET (811 BAU/mL, range 184 ->2500, p=0.001) patients. This difference was significant also comparing ET and PV (p=0.03). Also, a poorer response (Ab <60 BAU/mL) was observed in zero, 21.7% and 50% of ET, PV, and MF patients, respectively (p=0.007). Accordingly, no MF patient achieved a better response (compared to 46.1% and 30.5% in ET and PV, respectively, p=0.012). Analyzing the three diseases singularly, no clinical-laboratory characteristic, including disease duration, was associated with median Ab titers. However, among MF patients, a higher frequency of lower response was observed in patients with spleen palpable >5 cm below costal margin (85.7% versus 22.2% in patients with smaller spleen, p=0.012). This was confirmed also evaluating only ruxolitinib-treated MF patients (p=0.01). In MF, Dynamic International Prognostic Score system (DIPSS) risk category [15] was not associated with the Ab response (p = 0,48). At the time of the serological test, 18 patients (34.6%) were receiving cytoreductive drugs (hydroxyurea, anagrelide, busulfan), 6 patients (11.5%) interferon, and 22 patients (42.3%) ruxolitinib. Six patients were off treatment. Median ruxolitinib duration was 2.6 years (range, 0.4-16.8) and median ruxolitinib dose was 10 mg BID, with 18.2%, 63.6%, 5.6% and 13.6% patients receiving 5, 10, 15 and 20 mg BID, respectively. The use of ruxolitinib was associated with significantly decreased median Ab titers (33.1 BAU/mL versus 396.5 BAU/ml cytoreduction, p=0.003; versus 733.5 BAU/ml interferon, p=0.005; versus 583.5 BAU/ml in off-therapy patients, p=0.007). In MF, this effect was particularly evident (median Ab titer 32.2 BAU/mL versus 233.5 in patients who were not receiving ruxolitinib, p=0.05). In PV, only a trend for lower median Ab titers was observed (119.3 BAU/mL versus 393 BAU/ml, p=0.09). Additionally, lower response was mainly observed in patients treated with ruxolitinib, both overall (59.1% vs 0) and singularly in the PV (50% vs 0) and MF cohorts (66.7% vs 0). In multivariable analysis, including MPN diagnosis (PV versus MF), treatment (ruxolitinib versus no ruxolitinib) and palpable spleen at time of serologic evaluation, ruxolitinib therapy (p = 0.02) and splenomegaly (p= 0.04) remained associated with lower Ab titers. Importantly, ruxolitinib dose did not influence the response, with median Ab titers of 40 and 33 BAU/mL in patients receiving doses of 5-10 mg BID or >10 mg BID, respectively (p=0.86). Also, time on ruxolitinib (≥ 1 year or ≥ 2 years) was not associated with response (p=0.23 and 0.69, respectively). In PV and ET, interferon therapy was associated with a slightly higher median Ab titer compared to cytoreduction/no therapy (733 versus 410 BAU/mL, p=0.80). With the limitation of the small number of subjects included, we observed that median Ab titers, evaluated after more than one month from completion of vaccine program, are significantly greater in ET, intermediate in PV, and lower in MF. This is consistent with serological evaluations performed at earlier timepoints and it highlights the immunological differences across MPNs [1] . We also showed how ruxolitinib therapy, even more than disease type, may influence a later vaccine response. This finding reinforces the crucial argument of an impaired early humoral response to the SARS-CoV-2 vaccine in patients receiving ruxolitinib, and extends this issue to the later response as well [10] . However, the dose and duration of ruxolitinib did not affect Ab titers. Therefore, it may be advisable to wait for vaccine administration before starting ruxolitinib, if clinically acceptable, but there are no data to support a dose reduction of ruxolitinib in the perivaccinal period, nor to avoid or hasten vaccine administration in ruxolitinib-treated patients. Also, palpable splenomegaly was associated with a marked reduction in humoral response. This suggests, once again, how the severity of the hematological disease corresponds to a more critical immunologic disorder and is associated with vaccine humoral response. Notably, the rate of response in our cohort was high compared to previous observations [14] . Whether this finding is related to methodological issues, or to different timings of evaluation, remains unclear. Our study, being observational, did not investigate cellular response [16] . Recently, a memory T cell response, not affected by ruxolitinib therapy, was observed in 80% MPN patients after the first dose of the BNT162b2 vaccine [17] . Given its observational nature, the present study has several limitations, including the possibility for selection bias, that may affect the greater-than-expected serological response in MF. Also, the evaluation of no-spike IgG does not entirely exclude the possibility of previous infection that has not seroconverted, especially for the patients on ruxolitinib [18] . Overall, these data highlight the correlation between lower Ab titer, ruxolitinib therapy, and MPN severity. A third vaccine dose must be administered early in patients with MF and PV, particularly those on ruxolitinib therapy and/or with uncontrolled splenomegaly. All patients should continue to take the best preventive measures against COVID-19 even after receiving vaccination. J o u r n a l P r e -p r o o f Myeloproliferative Neoplasms during the COVID-19 Pandemic: Challenges and Future Scenarios High mortality rate in COVID-19 patients with myeloproliferative neoplasms after abrupt withdrawal of ruxolitinib Vaccinazione per COVID-19 nei pazienti con malattie del sangue e sottoposti a trapianto di cellule staminali COVID-19 and Myeloproliferative Neoplasms -Hematology.org Statements for vaccination against COVID-19 in patients with cancer Risk factors for infections in myelofibrosis: role of disease status and treatment. A multicenter study of 507 patients An immune dysregulation in MPN Fifth-week immunogenicity and safety of anti-SARS-CoV-2 BNT162b2 vaccine in patients with multiple myeloma and myeloproliferative malignancies on active treatment: preliminary data from a single institution Lower response to BNT162b2 vaccine in patients with myelofibrosis compared to polycythemia vera and essential thrombocythemia Impaired response to first SARS-CoV-2 dose vaccination in myeloproliferative neoplasm patients receiving ruxolitinib BNT162b2 COVID-19 vaccine is significantly less effective in patients with hematologic malignancies Impaired antibody response to COVID-19 vaccination in patients with chronic myeloid neoplasms The Slower Antibody Response in Myelofibrosis Patients after Two Doses of mRNA SARS-CoV-2 Vaccine Calls for a Third Dose Antibody Response to COVID-19 Vaccination in Adults with Haematological Malignancies: A Systematic Review and Meta-Analysis A dynamic prognostic model to predict survival in primary myelofibrosis: a study by the IWG-MRT (International Working Group for Myeloproliferative Neoplasms Research and Treatment) Bar-Or, Cellular and humoral immune responses following SARS-CoV-2 mRNA vaccination in patients with multiple sclerosis on anti-CD20 therapy Single dose of BNT162b2 mRNA vaccine against SARS-CoV-2 induces high frequency of neutralising antibody and polyfunctional T-cell responses in patients with myeloproliferative neoplasms ITA-HEMA-COV Investigators*, COVID-19 elicits an impaired antibody response against SARS-CoV-2 in patients with haematological malignancies J o u r n a l P r e -p r o o f The authors declare no competing interests. No therapy (2) median Ab titer 223.5 U/mL, range 127 -320 Cytoreduction (2) median Ab titer >2500 U/mL, range 1325 ->2500Ruxolitinib (12) median Ab titer 32.2 U/mL, range 0.64 -529