COVID-19 vaccine-readiness for ocrelizumab and other anti-CD20-depleting
therapies in multiple sclerosis and other autoimmune diseases
Abstract
Although most autoimmune diseases are considered to be CD4 T-cell or
antibody-mediated, many respond to CD20-depleting antibodies that have
limited influence on CD4 and plasma cells. This includes rituximab that
is used in cancer, rheumatoid arthritis and off-label in a large number
of other autoimmunities, notably multiple sclerosis, where ofatumumab is
in late stage development and ocrelizumab is approved for use. Recently,
the COVID-19 pandemic created concerns about immunosuppression in
autoimmunity, leading to cessation or a delay in immunotherapy
treatments. However, based on the known and emerging biology of multiple
sclerosis and COVID-19, it was hypothesised that whilst B-cell depletion
should not necessarily expose people to severe SARS-CoV-2-related
issues, it may inhibit protective immunity following infection and
vaccination. As such, drug-induced B-cell subset inhibition that
controls multiple sclerosis and other autoimmunities, would not
influence innate and CD8 T-cell responses, which are central to
SARS-CoV-2 elimination, nor the hyper-coagulation and innate
inflammation causing severe morbidity. This is supported clinically, as
the majority (mortality rate n=~5/392) of SARS-CoV-2
infected, CD20-depleted people with multiple sclerosis have recovered.
However, protective neutralising-antibody and vaccination responses are
predicted to be blunted, until naïve B-cells repopulate, based on B-cell
repopulation-kinetics and vaccination responses, from published
rituximab and unpublished ocrelizumab (NCT00676715, NCT02545868) trial
data, shown here. This suggests that it may be possible to undertake
dose-interruption to maintain inflammatory disease control in MS and
other autoimmune diseases, whilst allowing effective vaccination against
SARS-CoV-29, if and when an effective vaccine is available.