key: cord-0827065-5o0ihd3f
authors: Chanchlani, Neil; Lin, Simeng; Chee, Desmond; Hamilton, Benjamin; Nice, Rachel; Arkir, Zehra; Bewshea, Claire; Cipriano, Bessie; Derikx, Lauranne A A P; Dunlop, Allan; Greathead, Louise; Griffiths, Rachel L; Ibraheim, Hajir; Kelleher, Peter; Kok, Klaartje B; Lees, Charlie W; MacDonald, Jonathan; Sebastian, Shaji; Smith, Philip J; McDonald, Timothy J; Irving, Peter M; Powell, Nick; Kennedy, Nicholas A; Goodhand, James R; Ahmad, Tariq
title: Adalimumab and Infliximab Impair SARS-CoV-2 Antibody Responses: Results from a Therapeutic Drug Monitoring Study in 11 422 Biologic-Treated Patients
date: 2021-09-02
journal: J Crohns Colitis
DOI: 10.1093/ecco-jcc/jjab153
sha: c3bcc4acf7cc1ccf428c376064ec7a4f7451ed63
doc_id: 827065
cord_uid: 5o0ihd3f

BACKGROUND AND AIMS: Infliximab attenuates serological responses to SARS-CoV-2 infection. Whether this is a class effect, or if anti-tumour necrosis factor [anti-TNF] level influences serological responses, remains unknown. METHODS: Seroprevalence and the magnitude of SARS-CoV-2 nucleocapsid antibody responses were measured in surplus serum from 11 422 (53.3% [6084] male; median age 36.8 years) patients with immune-mediated inflammatory diseases, stored at six therapeutic drug monitoring laboratories between January 29 and September 30, 2020. Data were linked to nationally held SARS-CoV-2 PCR results to July 11, 2021. RESULTS: Rates of PCR-confirmed SARS-CoV-2 infection were similar across treatment groups. Seroprevalence rates were lower in infliximab- and adalimumab- than vedolizumab-treated patients (infliximab: 3.0% [178/5893], adalimumab: 3.0% [152/5074], vedolizumab: 6.7% [25/375], p = 0.003). The magnitude of SARS-CoV-2 reactivity was similar in infliximab- vs adalimumab-treated patients (median 4.30 cut-off index [COI] [1.94–9.96] vs 5.02 [2.18–18.70], p = 0.164), but higher in vedolizumab-treated patients (median 21.60 COI [4.39–68.10, p < 0.004). Compared to patients with detectable infliximab and adalimumab drug levels, patients with undetectable drug levels [<0.8 mg/L] were more likely to be seropositive for SARS-CoV-2 antibodies. One-third of patients who had PCR testing prior to antibody testing failed to seroconvert, all were treated with anti-TNF. Subsequent positive PCR-confirmed SARS-CoV-2 was seen in 7.9% [12/152] of patients after a median time of 183.5 days [129.8–235.3], without differences between drugs. CONCLUSION: Anti-TNF treatment is associated with lower SARS-CoV-2 nucleocapsid seroprevalence and antibody reactivity when compared to vedolizumab-treated patients. Higher seropositivity rates in patients with undetectable anti-TNF levels support a causal relationship, although confounding factors, such as combination therapy with a immunomodulator, may have influenced the results.

The increased transmissibility of the dominant delta variant of SARS-CoV-2 means that > 80% of the UK population will need to be fully vaccinated to achieve herd immunity. 1 Anti-tumour necrosis factor [anti-TNF] drugs impair protective immunity following pneumococcal, 2 influenza 3,4 and viral hepatitis 5 vaccinations and increase the risk of serious respiratory infections. 6 By suppressing immune responses, biologic and immunosuppression therapies increase the reservoir for viral transmission and have been implicated in the evolution and emergence of novel variants of SARS-CoV-2. 7 We have recently reported that seroprevalence, seroconversion rates and the magnitude of SARS-CoV-2 nucleocapsid [N] antibodies following SARS-CoV-2 infection are reduced in patients with inflammatory bowel disease [IBD] treated with infliximab compared to vedolizumab. 8 Vedolizumab is a gut-selective anti-integrin α4β7 monoclonal antibody and, unlike anti-TNF therapy, is not associated with increased susceptibility to systemic infection or attenuated serological responses to SARS-CoV-2 vaccination. 9 Because we observed similar rates of SARS-CoV-2 infection and hospitalizations between infliximab-and vedolizumab-treated patients, our findings suggest that infliximab directly influences the serological response to SARS-CoV-2 infection. In the same cohort of IBD patients, SARS-CoV-2 spike [S] antibody levels and rates of seroconversion were also lower after a single-dose of either the BNT162b2 [Pfizer] or ChAdOx1 nCoV-19 [AstraZeneca/Oxford] vaccines in patients treated with infliximab than vedolizumab. 10 Whether antibody responses following SARS-CoV-2 infection are also impaired in patients treated with other biopharmaceuticals, including other anti-TNF therapies such as adalimumab, and whether biologic drug levels influence the magnitude of SARS-CoV-2 [N] antibody responses, remain unknown.

In patients with immune-mediated inflammatory diseases [IMIDs], we aimed to define whether biologic class impacted the: 

CLARITY IBD is a UK-wide, multicentre, observational cohort study investigating the impact of biologics and/or concomitant immunomodulators on SARS-CoV-2 acquisition, illness and immunity in patients with IBD [www.clarityibd.org].

Here, we report data from a retrospective cohort of patients with IMIDs who had serum stored following routine therapeutic drug monitoring [TDM] tests as part of clinical care during the early phase of the COVID-19 pandemic. Surplus serum samples were obtained from six UK laboratories [Barts Health NHS Trust, NHS Greater Glasgow and Clyde, Guy's and St Thomas' NHS Foundation Trust, North West London Pathology, Royal Devon and Exeter NHS Foundation Trust, and Royal Wolverhampton NHS Trust] that offer TDM for infliximab, adalimumab, ustekinumab or vedolizumab. Samples archived between January 29, 2020, shortly after the first case of COVID-19 was reported in the UK, 11 to September 30, 2020 were included. Surplus samples were transferred to the Academic Department of Blood Sciences at the Royal Devon and Exeter NHS Foundation Trust and serum was tested for SARS-CoV-2 [N] antibodies. Samples with adequate linked clinical data, of more than 150 µL, the minimum volume required to undertake the assay, and not contaminated by haemolysis, were processed.

The primary outcome was the proportion of patients with a positive SARS-CoV-2 [N] antibody test. Secondary outcomes were the impact of biologic drug levels on seropositivity and the magnitude of SARS-CoV-2 antibodies, and seroconversion and rates of subsequent positive PCR-confirmed SARS-CoV-2. 

We used the Roche Elecsys Anti-SARS-CoV-2 [N] immunoassay to detect antibodies to SARS-CoV-2. This sandwich electrochemiluminescence immunoassay uses a recombinant protein of the nucleocapsid antigen for determination of antibodies against SARS-CoV-2. 12 The electrochemiluminescence signal from a negative and positive calibrator are assigned a value of 0.8 and 1.2, respectively, and a cut-off index [COI] is set at a signal equivalent to 1. The manufacturer reports clinical sensitivity of 99.5% [97.0-100] ≥ 14 days post-PCR confirmation and specificity of 99.8% [95% CI 99.7-99.9]. 12 In-house assay validation experiments demonstrated the intraand inter-assay coefficient of variation were 2.2 and 7.0%, respectively. No effect was observed on recovery of SARS-CoV-2 antibodies following four freeze/thaw cycles. SARS-CoV-2 antibodies were stable in uncentrifuged blood and serum at ambient temperature for up to 7 days, permitting postal transport from research sites to the central laboratory. No analytical interference was observed for the detection of SARS-CoV-2 antibodies with infliximab, adalimumab or vedolizumab up to 10 000, 8000 and 60 000 mg/L, respectively, or with anti-drug antibodies to infliximab, adalimumab or vedolizumab up to 400, 200 and 38 AU/mL respectively. For anti-TNF-treated patients, absence of drug was defined using a cut-off of < 0.8 mg/L. 13 For vedolizumab-treated patients, absence of drug was defined using a cut-off of < 3.1 mg/L. Anti-drug antibody levels, recorded as positive or negative, were supplied by the referring laboratory.

A priori sample size calculations were not undertaken for this study; rather we collected all available samples saved through the early phase of the pandemic. Statistical analyses were undertaken in R 4.0.5 [R Foundation for Statistical Computing]. All tests were two tailed and p-values < 0.05 were considered significant. We included patients with missing clinical data in analyses for which they had data and have specified the denominator for each variable. Continuous data were reported as median and interquartile range [IQR] , and discrete data as numbers and percentages, unless otherwise stated. We used patients' postcodes to assign them to one of ten UK administrative regions and present seroprevalence rates mapped to these regions. We also used postcodes to derive patients' income and employment deprivation scores using combined English and Welsh data from 2019 14 and Scottish data from 2020. 15 Seroprevalence of SARS-CoV-2 antibodies was estimated as the proportion of samples with a positive SARS-CoV-2 antibody result. Univariable analyses, using Fisher's exact and Mann-Whitney U tests, were used to identify demographic and treatment-related factors, including TDM, associated with SARS-CoV-2 seropositivity. We explored the magnitude of antibody reactivity using density plots, stratified by drug exposure among patients with a positive SARS-CoV-2 antibody result. We performed a sensitivity analysis restricting the cohort to patients treated with an anti-TNF who were known to have IBD, and all vedolizumab-treated patients, which is only licensed in the UK for treatment of IBD. 

In total, 14 106 surplus samples were received; 4.2% of samples [597/14 106] were excluded because of insufficient demographic or clinical information, insufficient volume or haemolysis, leaving 13 509 samples from 11 600 patients to be analysed. Of these, 1.5% [178/11 600] patients did not have adequate treatment details [n = 176] or were treated with etanercept [n = 2], and therefore excluded. In total, 13 316 samples from 11 422 unique patients were included in the final analysis [ Figure 1 ; Supplementary Figures 1 and 2 

Seropositivity to SARS-CoV-2 was first observed on February 3, 2020 and seroprevalence increased to 3.1% by September 30, 2020 [Supplementary Figure 3 ]. Univariable analyses demonstrated that the proportion of patients with a positive SARS-CoV-2 antibody test was lower in anti-TNF-and ustekinumab-treated patients than vedolizumab-treated patients (infliximab: 3 Similarly, compared to patients with detectable adalimumab drug levels [≥ 0.8 mg/L], patients with undetectable drug levels were more likely to be seropositive for SARS-CoV-2 antibodies [OR 1.72, 95% CI 0.96-2.90, p = 0.04; Figure 2B ], but there was no difference in the magnitude of SARS-CoV-2 antibodies (median COI 8.49 There was no association between vedolizumab drug levels and seropositivity or the magnitude of SARS-CoV-2 antibodies [ Figure  2B ]. Compared to vedolizumab-treated patients, infliximab-and adalimumab-treated patients with undetectable drug levels had similar seropositivity rates (infliximab: 4 

We have shown that patients with IMIDs treated with infliximab and adalimumab have attenuated serological responses to SARS-CoV-2 infection with lower seroprevalence and antibody reactivity when compared to vedolizumab-treated patients. Amongst patients treated with adalimumab and infliximab, seropositivity rates were highest in patients with undetectable drug levels and were similar to those observed in patients treated with vedolizumab. One-third of our cohort who had PCR-confirmed SARS-CoV-2 infection, all of whom were treated with anti-TNF therapy, subsequently did not develop SARS-CoV-2 antibodies. Subsequent positive PCR-confirmed SARS-CoV-2 was observed in 8% patients. Like infliximab, 8 adalimumab impairs antibody responses following SARS-CoV-2 infection, and we observed that higher SARS-CoV-2 antibody levels were associated with undetectable infliximab and adalimumab drug levels. This is biologically plausible since anti-TNF drugs directly impede the immune mechanisms responsible for generating antibody responses, including maturation of antigen presenting cells and co-stimulation of antigen-specific T-cells. [16] [17] [18] TNF neutralization, or genetic ablation, results in reduced B-cells in primary follicles in germinal centres and the periphery, and B-cell immunoglobulin synthesis. 16 In keeping with this hypothesis, in infliximab-treated patients, the highest SARS-CoV-2 antibody concentrations were seen in patients with undetectable drug levels in the presence of anti-infliximab antibodies where drug is absent. 19, 20 It is possible that this cohort of patients were less likely to be treated with an immunomodulator, which we have previously shown is independently associated with SARS-CoV-2 seroconversion in infliximabtreated patients with IBD. 8 An alternative explanation for our results is that anti-TNF agents in IMIDs prevent severe COVID-19 infection and consequently immune responses. 21 Against this postulate, we previously observed no difference in rates of hospitalization for confirmed COVID-19 amongst infliximab-compared to vedolizumabtreated patients with IBD, and that vaccine responses were similarly impaired in anti-TNF-treated patients. 8, 10 Even after PCR-confirmed infection, one-third of patients who were subsequently tested for SARS-CoV-2 antibodies, and all of whom were treated with either adalimumab or infliximab, failed to mount an antibody response. Whilst this might be explained by antibody decay in the period between the positive PCR test and SARS-CoV-2 antibody test, we reported similar findings in our prospective cohort of patients with IBD, where 52% [42/81] of infliximabtreated patients did not mount an antibody response following PCRconfirmed infection. 8 Whether a failure to seroconvert after infection predisposes people to recurrent SARS-CoV-2 infection cannot be determined in this cohort because of a paucity of PCR testing in the early phase of the pandemic. However, following a positive SARS-CoV-2 antibody test, over 7% of patients subsequently had PCR-confirmed SARS-CoV-2. We acknowledge that none of these 12 patients had a positive PCR test prior to their initial SARS-CoV-2 antibody test and it is therefore possible that these patients may have had false positive antibody tests. An alternative explanation is that these patients may have failed to clear a primary SARS-CoV-2 infection or had a second infection.

The main strength of this study was analysis of SARS-CoV-2 antibodies on more than 13 000 samples from 11 422 unique patients with IMIDs treated with biologic therapy during the early phase of the pandemic. Other strengths include correlation with comprehensive biologic drug-level data, and linkage with SARS-CoV-2 public health testing data. We acknowledge, however, the following limitations. First, because this was an analysis of surplus serum, clinical details were infrequently entered on requisition forms. We therefore did not have access to comprehensive clinical data for study subjects including comorbidities, ethnicity, diagnosis, symptoms of suspected COVID-19, and indications for, and duration of, biologic and concomitant therapies. Second, as serum samples for this study were collected early in the pandemic, a limited number of subjects had PCR-confirmed infection. Third, our ability to interpret SARS-CoV-2 antibody durability and risk of re-infection was limited by the duration of follow-up, frequency of sampling and the availability of the first positive PCR test results conducted in England. Finally, as this study involved surplus serum samples used for TDM, limited data were available for patients treated with therapies for which TDM is not widely used, including ustekinumab.

From a public health perspective, attention has turned from natural infection to vaccine effectiveness in the face of novel SARS-CoV-2 variants. Several groups have shown that most patients with IBD can mount an effective immune response in the short term following both licensed doses of SARS-CoV-2 vaccine. [22] [23] [24] [25] [26] [27] Urgent research is needed to understand the factors linked to vaccine nonresponse. For patients who need to start anti-TNF therapy, they and their families should receive SARS-CoV-2 vaccines without a delay between vaccine doses, wherever possible before anti-TNF therapies are started. Whether timing booster doses towards the end of an anti-TNF treatment cycle when drug levels are lowest, 28 and/or the temporary discontinuation of immunomodulators, 29 potentiate 30 and/or switching between vaccines with different mechanisms of action. 31

Patients with IMIDs treated with infliximab and adalimumab have attenuated serological responses to SARS-CoV-2 when compared to vedolizumab-treated patients. Seropositivity rates were highest in patients with undetectable drug levels and were similar to those observed in patients treated with vedolizumab, supporting a causal relationship between anti-TNF use and attenuated antibody responses to infection, although confounding factors, such as combination therapy with an immunomodulator, may have influenced the results.

Dr Lin reports non-financial support from Pfizer, non-financial support from Ferring, outside the submitted work. Dr Chee reports non-financial support from Ferring, personal fees and non-financial support from Pfizer, outside the submitted work. Dr Derikx has served on the advisory board for Sandoz, outside the submitted work. Dr Kelleher reports financial support from Pfizer, Wellcome Trust, UKRI and non-financial support from Oxford Immunotech outside the submitted work. Dr Kok reports personal fees from Janssen, personal fees from Takeda, personal fees from PredictImmune, and personal fees from Amgen, outside the submitted work. Dr Lees reports personal fees from Abbvie, personal fees from Janssen, personal fees from Pfizer, personal fees from Takeda, grants from Gilead, personal fees from Gilead, personal fees from Galapagos, personal fees from Iterative Scopes, personal fees from Trellus Health, personal fees from Celltion, personal fees from Ferring, and personal fees from BMS, during the conduct of the study. Dr Macdonald reports grants and personal fees from Takeda Pharmaceuticals, grants and personal fees from Biogen, personal fees and non-financial support from AbbVie, personal fees from Grifols, personal fees from Sandoz, personal fees from Celltrion, personal fees and non-financial support from Janssen, personal fees from Vifor Pharmaceuticals, personal fees from Predictimmune, personal fees from Bristol Myers Squibb, and non-financial support from Ferring Pharmaceuticals, outside the submitted work. Dr Shaji reports grants from Takeda, Abbvie, AMGEN, Tillots Pharma, and personal fees from Jaansen, Takeda, Galapagos, Celltrion, Falk Pharma, Tillots pharma, Cellgene, Pfizer and Phamrmacocosmos, outside the submitted work. Dr Philip J. Smith reports speaker fees and advisory board sponsorship from Janssen, Celltrion and Takeda outside the submitted work. Dr Irving reports grants and personal fees from Takeda, grants from MSD, grants and personal fees from Pfizer, personal fees from Galapagos, personal fees from Gilead, personal fees from Abbvie, personal fees from Janssen, personal fees from Boehringer Ingelheim, personal fees from Topivert, personal fees from VH2, personal fees from Celgene, personal fees from Arena, personal fees from Samsung Bioepis, personal fees from Sandoz, personal fees from Procise and personal fees from Prometheus, outside the submitted work. Dr Powell reports personal fees from Takeda, personal fees from Janssen, personal fees from Pfizer, personal fees from Bristol-Myers Squibb, personal fees from Abbvie, personal fees from Roche, personal fees from Lilly, personal fees from Allergan and personal fees from Celgene, outside the submitted work; and Dr Powell has served as a speaker/ advisory board member for Abbvie, Allergan, Bristol Myers Squibb, Celgene, Falk, Ferring, Janssen, Pfizer, Tillotts, Takeda and Vifor Pharma. Dr Kennedy reports grants from F. Hoffmann-La Roche AG, grants from Biogen Inc, grants from Celltrion Healthcare, grants from Galapagos NV and non-financial support from Immundiagnostik, during the conduct of the study; grants and non-financial support from AbbVie, grants and personal fees from Celltrion, personal fees and non-financial support from Janssen, personal fees from Takeda, and personal fees and non-financial support from Dr Falk, outside the submitted work. Dr Goodhand reports grants from F. Hoffmann-La Roche AG, grants from Biogen Inc, grants from Celltrion Healthcare, grants from Galapagos NV and non-financial support from Immundiagnostik, during the conduct of the study. Dr Ahmad reports grants and non-financial support from F. Hoffmann-La Roche AG, grants from Biogen Inc, grants from Celltrion Healthcare, grants from Galapagos NV and non-financial support from Immundiagnostik, during the conduct of the study; personal fees from Biogen inc, grants and personal fees from Celltrion Healthcare, personal fees and non-financial support from Immundiagnostik, personal fees from Takeda, personal fees from ARENA, personal fees from Gilead, personal fees from Adcock Ingram Healthcare, personal fees from Pfizer, personal fees from Genentech and non-financial support from Tillotts, outside the submitted work. Neil 

The Exeter IBD Patient Panel reviewed the study protocol. A member of the Exeter IBD Patient Panel sits on the study management committee, ensuring patient involvement in all aspects of study delivery, data analysis and dissemination of findings.

The study protocol including the statistical analysis plan is available at www. clarityibd.org. Individual participant de-identified data that underlie the results reported in this article will be available immediately after publication for a period of 5 years. The data will be made available to investigators whose proposed use of the data has been approved by an independent review committee. Analyses will be restricted to the aims in the approved proposal. Proposals should be directed to tariq.ahmad1@nhs.net; to gain access data requestors will need to sign a data access agreement.

The potential for vaccination-induced herd immunity against the SARS-CoV-2 B.1.1.7 variant

Immunosuppression impairs response to pneumococcal polysaccharide vaccination in patients with inflammatory bowel disease

Immunogenicity of high dose influenza vaccine for patients with inflammatory bowel disease on anti-TNF monotherapy: a randomized clinical trial

The effect of infliximab and timing of vaccination on the humoral response to influenza vaccination in patients with rheumatoid arthritis and ankylosing spondylitis

Antibody response to hepatitis B virus vaccine is impaired in patients with inflammatory bowel disease on infliximab therapy

Increased risk of pneumonia among patients with inflammatory bowel disease

CITIID-NIHR BioResource COVID-19 Collaboration

SARS-CoV-2 evolution during treatment of chronic infection

Contributors to the CLARITY IBD study. Anti-SARS-CoV-2 antibody responses are attenuated in patients with IBD treated with infliximab

The immunogenicity of the influenza, pneumococcal, and hepatitis B vaccines in patients with inflammatory bowel disease treated with vedolizumab. Crohn's

Infliximab is associated with attenuated immunogenicity to BNT162b2 and ChAdOx1 nCoV-19 SARS-CoV-2 vaccines in patients with IBD

Novel coronavirus disease (Covid-19): The first two patients in the UK with person to person transmission

Development and validation of the elecsys anti-SARS-CoV-2 immunoassay as a highly specific tool for determining past exposure to SARS-CoV-2

Detection of infliximab levels and anti-infliximab antibodies: a comparison of three different assays

Ministry of Housing C& LG. Indices of Deprivation 2019: income and employment domains combined for England and Wales. 2020. Available at

Scottish index of multiple deprivation

Immune and inflammatory responses in TNF alpha-deficient mice: a critical requirement for TNF alpha in the formation of primary B cell follicles, follicular dendritic cell networks and germinal centers, and in the maturation of the humoral immune response

Analysis of the maturation process of dendritic cells deficient for TNF and lymphotoxin-alpha reveals an essential role for TNF

Anti-TNF treatment blocks the induction of T cell-dependent humoral responses

The relationship between infliximab concentrations, antibodies to infliximab and disease activity in Crohn's disease

Predictors of anti-TNF treatment failure in anti-TNF-naive patients with active luminal Crohn's disease: a prospective, multicentre, cohort study

Antibody response patterns in COVID-19 patients with different levels of disease severity in Japan

Effectiveness of SARS-CoV-2 vaccination in a veterans affairs cohort of inflammatory bowel disease patients with diverse exposure to immunosuppressive medications

Glucocorticoids and B cell depleting agents substantially impair immunogenicity of mRNA vaccines to SARS-CoV-2. medRxiv

Serologic response to messenger RNA coronavirus disease 2019 vaccines in inflammatory bowel disease patients receiving biologic therapies

Humoral immune response to mRNA COVID019 vaccines among patients with IBD

Case study: prolonged infectious SARS-CoV-2 shedding from an asymptomatic immunocompromised individual with cancer

COVID-19 vaccination is safe and effective in patients with inflammatory bowel disease: Analysis of a large multi-institutional research network in United States

Preliminary analysis of safety and immunogenicity of a SARS-CoV-2 variant vaccine booster. medRxiv 2021

Effect of methotrexate discontinuation on efficacy of seasonal influenza vaccination in patients with rheumatoid arthritis: a randomised clinical trial

ISRCTN. ISRCTN14391248: combining influenza and COVID-19 vaccination (ComFluCOV) study. 2021. Available at

Immune responses against SARS-CoV-2 variants after heterologous and homologous ChAdOx1 nCoV-19/BNT162b2 vaccination

Supplementary data are available at ECCO-JCC online.