Methotrexate and immunogenicity of vaccines in patients with rheumatic diseases

Currently, methotrexate (MT) remains one of the immunosuppressive drugs most commonly used in rheumatology. However, its effect on the immunogenicity of vaccines has until recently been studied only to a limited extent, which has led to the lack of clear recommendations for the use of MT during vaccination. Significant progress was made during the COVID-19 pandemic due to the dynamic development of vaccine research, including in patients with immuno-inflammatory rheumatic diseases. The review presents data on the effect of MT on the immunogenicity of vaccines against influenza, pneumococcus, herpes zoster, tetanus/diphtheria/pertussis, yellow fever and COVID-19 (including humoral and cellular responses) in rheumatological patients. The necessity of observing certain time intervals during vaccination in the case of MT use has been demonstrated. The potential mechanisms by which MT influences the immunogenicity of vaccines are presented. The importance of further clinical studies is emphasized in order to assess the effect of MT therapy on the vaccine response and to develop methods for its optimization.

1. Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2020;79(1):39-52. doi: 10.1136/annrheumdis-2019-215882

2. Dirven L, Huizinga TWJ, Allaart CF. Risk factors for reported influenza and influenza-like symptoms in patients with rheumatoid arthritis. Scand J Rheumatol. 2012;41:359-365. doi: 10.3109/03009742.2012.670729

3. Bower H, Frisell T, Di Giuseppe D, Delcoigne B, Askling J. Influenza outcomes in patients with inflammatory joint diseases and DMARDs: How do they compare to those of COVID-19? Ann Rheum Dis. 2022;81(3):433-439. doi: 10.1136/annrheumdis-2021-221461

4. Blumentals WA, Arreglado A, Napalkov P, Toovey S. Rheumatoid arthritis and the incidence of influenza and influenza-related complications: A retrospective cohort study. BMC Musculoskelet Disord. 2012;13:158. doi: 10.1186/1471-2474-13-158

5. Fomin I, Caspi D, Levy V, Varsano N, Shalev Y, Paran D, et al. Vaccination against influenza in rheumatoid arthritis: The effect of disease modifying drugs, including TNF alpha blockers. Ann Rheum Dis. 2006;65(2):191-194. doi: 10.1136/ard.2005.036434

6. Kapetanovic MC, Kristensen LE, Saxne T, Aktas T, Mörner A, Geborek P. Impact of anti-rheumatic treatment on immunogenicity of pandemic H1N1 influenza vaccine in patients with arthritis. Arthritis Res Ther. 2014;16(1):R2. doi: 10.1186/ar4427

7. Hua C, Barnetche T, Combe B, Morel J. Effect of methotrexate, anti-tumor necrosis factor α, and rituximab on the immune response to influenza and pneumococcal vaccines in patients with rheumatoid arthritis: A systematic review and meta-analysis. Arthritis Care Res (Hoboken). 2014;66(7):1016-1026. doi: 10.1002/acr.22246

8. van Assen S, Holvast A, Benne CA, Posthumus MD, van Leeuwen MA, Voskuyl AE, et al. Humoral responses after influenza vaccination are severely reduced in patients with rheumatoid arthritis treated with rituximab. Arthritis Rheum. 2010;62(1):75-81. doi: 10.1002/art.25033

9. Gabay C, Bel M, Combescure C, Ribi C, Meier S, PosfayBarbe K, et al.; H1N1 Study Group. Impact of synthetic and biologic disease-modifying antirheumatic drugs on antibody responses to the AS03-adjuvanted pandemic influenza vaccine: A prospective, open-label, parallel-cohort, single-center study. Arthritis Rheum. 2011;63(6):1486-1496. doi: 10.1002/art.30325

10. França IL, Ribeiro AC, Aikawa NE, Saad CG, Moraes JC, Goldstein-Schainberg C, et al. TNF blockers show distinct patterns of immune response to the pandemic influenza A H1N1 vaccine in inflammatory arthritis patients. Rheumatology (Oxford). 2012;51(11):2091-2098. doi: 10.1093/rheumatology/kes202

11. Ribeiro AC, Guedes LK, Moraes JC, Saad CG, Aikawa NE, Calich AL, et al. Reduced seroprotection after pandemic H1N1 influenza adjuvant-free vaccination in patients with rheumatoid arthritis: Implications for clinical practice. Ann Rheum Dis. 2011;70(12):2144-2147. doi: 10.1136/ard.2011.152983

12. Park JK, Lee YJ, Shin K, Ha YJ, Lee EY, Song YW, et al. Impact of temporary methotrexate discontinuation for 2 weeks on immunogenicity of seasonal influenza vaccination in patients with rheumatoid arthritis: A randomised clinical trial. Ann Rheum Dis. 2018;77(6):898-904. doi: 10.1136/annrheumdis-2018-213222

13. Park JK, Lee YJ, Shin K, Kang EH, Ha YJ, Park JW, et al. A multicenter, prospective, randomized, parallel-group trial on the effects of temporary methotrexate discontinuation for one week versus two weeks on seasonal influenza vaccination in patients with rheumatoid arthritis. Arthritis Rheumatol. 2023;75(2):171-177. doi: 10.1002/art.42318

14. Subesinghe S, Bechman K, Rutherford AI, Goldblatt D, Galloway JB. A systematic review and metaanalysis of antirheumatic drugs and vaccine immunogenicity in rheumatoid arthritis. J Rheumatol. 2018;45(6):733-744. doi: 10.3899/jrheum.170710

15. Adler S, Krivine A, Weix J, Rozenberg F, Launay O, Huesler J, et al. Protective effect of A/H1N1 vaccination in immune-mediated disease – A prospectively controlled vaccination study. Rheumatology (Oxford). 2012;51(4):695-700. doi: 10.1093/rheumatology/ker389

16. Park JK, Lee MA, Lee EY, Song YW, Choi Y, Winthrop KL, et al. Effect of methotrexate discontinuation on efficacy of seasonal influenza vaccination in patients with rheumatoid arthritis: A randomised clinical trial. Ann Rheum Dis. 2017;76(9):1559-1565. doi: 10.1136/annrheumdis-2017-211128

17. Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, et al. 2022 American College of Rheumatology guideline for vaccinations in patients with rheumatic and musculoskeletal diseases. Arthritis Rheumatol. 2023;75(3):333-348. doi: 10.1002/art.42386

18. Kapetanovic MC, Saxne T, Sjöholm A, Truedsson L, Jönsson G, Geborek P. Influence of methotrexate, TNF blockers and prednisolone on antibody responses to pneumococcal polysaccharide vaccine in patients with rheumatoid arthritis. Rheumatology. 2006;45(1):106-111. doi: 10.1093/rheumatology/kei193

19. Kapetanovic MC, Roseman C, Jönsson G, Truedsson L, Saxne T, Geborek P. Antibody response is reduced following vaccination with 7-valent conjugate pneumococcal vaccine in adult methotrexate-treated patients with established arthritis, but not those treated with tumor necrosis factor inhibitors. Arthritis Rheum. 2011;63(12):3723-3732. doi: 10.1002/art.30580

20. Bingham CO 3rd, Looney RJ, Deodhar A, Halsey N, Greenwald M, Codding C, et al. Immunization responses in rheumatoid arthritis patients treated with rituximab: Results from a controlled clinical trial. Arthritis Rheum. 2010;62(1):64-74. doi: 10.1002/art.25034

21. Nived P, Saxne T, Geborek P, Mandl T, Skattum L, Kapetanovic MC. Antibody response to 13-valent pneumococcal conjugate vaccine is not impaired in patients with rheumatoid arthritis or primary Sjögren’s syndrome without disease modifying treatment. BMC Rheumatol. 2018;2:12. doi: 10.1186/s41927-018-0019-6

22. OʼDell JR, Gilg J, Palmer W, Haire C, Klassen L, Moore G. Pneumococcal vaccine in rheumatoid arthritis. J Clin Rheumatol. 1996;2(2):59-63. doi: 10.1097/00124743-199604000-00001

23. Mease PJ, Ritchlin CT, Martin RW, Gottlieb AB, Baumgartner SW, Burge DJ, et al. Pneumococcal vaccine response in psoriatic arthritis patients during treatment with etanercept. J Rheumatol. 2004;31(7):1356-1361.

24. Migita K, Akeda Y, Akazawa M, Tohma S, Hirano F, Ideguchi H, et al. Effect of abatacept on the immunogenicity of 23-valent pneumococcal polysaccharide vaccination (PPSV23) in rheumatoid arthritis patients. Arthritis Res Ther. 2015;17:357. doi: 10.1186/s13075-015-0863-3

25. Rasmussen SL, Fuursted K, Nielsen KA, Laurberg NP, Sørensen MB, Fagerberg SK, et al. Pneumococcal antibody protection in patients with autoimmune inflammatory rheumatic diseases with varying vaccination status. Scand J Rheumatol. 2020;49(5):353-360. doi: 10.1080/03009742.2020.1732459

26. van Aalst M, Langedijk AC, Spijker R, de Bree GJ, Grobusch MP, Goorhuis A. The effect of immunosuppressive agents on immunogenicity of pneumococcal vaccination: A systematic review and meta-analysis. Vaccine. 2018;36(39):5832-5845. doi: 10.1016/j.vaccine.2018.07.039

27. Coulson E, Saravanan V, Hamilton J, So KL, Morgan L, Heycock C, et al. Pneumococcal antibody levels after pneumovax in patients with rheumatoid arthritis on methotrexate. Ann Rheum Dis. 2011;70(7):1289-1291. doi: 10.1136/ard.2010.144451

28. Bühler S, Jaeger VK, Adler S, Bannert B, Brümmerhoff C, Ciurea A, et al. Safety and immunogenicity of tetanus/diphtheria vaccination in patients with rheumatic diseases – A prospective multicentre cohort study. Rheumatology (Oxford). 2019;58(9):1585-1596. doi: 10.1093/rheumatology/kez045

29. Holmes CL, Peyton CG, Bier AM, Donlon TZ, Osman F, Bartels CM, et al. Reduced IgG titers against pertussis in rheumatoid arthritis: Evidence for a citrulline-biased immune response and medication effects. PLoS One. 2019;14(5):e0217221. doi: 10.1371/journal.pone.0217221

30. Bingham CO 3rd, Rizzo W, Kivitz A, Hassanali A, Upmanyu R, Klearman M. Humoral immune response to vaccines in patients with rheumatoid arthritis treated with tocilizumab: Results of a randomised controlled trial (VISARA). Ann Rheum Dis. 2015;74(5):818-822. doi: 10.1136/annrheumdis-2013-204427

31. Bingham CO 3rd, Looney RJ, Deodhar A, Halsey N, Greenwald M, Codding C, et al. Immunization responses in rheumatoid arthritis patients treated with rituximab: Results from a controlled clinical trial. Arthritis Rheum. 2010;62(1):64-74. doi: 10.1002/art.25034

32. Kovac M, Kostanyan L, Mesaros N, Kuriyakose S, Varman M. Immunogenicity and safety of a second booster dose of an acellular pertussis vaccine combined with reduced antigen content diphtheriatetanus toxoids 10 years after a first booster in adolescence: An open, phase III, non-randomized, multi-center study. Hum Vaccin Immunother. 2018;14(8):1977-1986. doi: 10.1080/21645515.2018.1460292

33. Winthrop KL, Wouters AG, Choy EH, Soma K, Hodge JA, Nduaka CI, et al. The safety and immunogenicity of live zoster vaccination in patients with rheumatoid arthritis before starting tofacitinib: A randomized phase II trial. Arthritis Rheumatol. 2017;69(10):1969- 1977. doi: 10.1002/art.40187

34. Curtis JR, Cofield SS, Bridges SL Jr, Bassler J, Deodhar A, Ford TL, et al. The safety and immunologic effectiveness of the live varicella-zoster vaccine in patients receiving tumor necrosis factor inhibitor therapy: A randomized controlled trial. Ann Intern Med. 2021;174(11):1510-1518. doi: 10.7326/M20-6928

35. Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD, et al.; Shingles Prevention Study Group. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005;352(22):2271-2284. doi: 10.1056/NEJMoa051016

36. Eberhardson M, Hall S, Papp KA, Sterling TM, Stek JE, Pang L, et al. Safety and immunogenicity of inactivated varicella-zoster virus vaccine in adults with autoimmune disease: A phase 2, randomized, double-blind, placebo-controlled clinical trial. Clin Infect Dis. 2017;65(7):1174-1182. doi: 10.1093/cid/cix484

37. Koh JH, Lee J, Kim SH, Kwok SK, Ju JH, Park SH. Safety, and humoral and cell-mediated immune responses to herpes zoster vaccine in patients with rheumatoid arthritis. J Rheumatol. 2018;45(4):465-469. doi: 10.3899/jrheum.170936

38. Källmark H, Bergström T, Nagel J, Gullstrand B, Einarsson JT, Bengtsson AA, et al. Serologic immunogenicity and safety of Herpes Zoster subunit vaccine in patients with rheumatoid arthritis receiving Janus kinase inhibitors. Rheumatology (Oxford). 2023 Oct 18:kead552. doi: 10.1093/rheumatology/kead552

39. Scheinberg M, Guedes-Barbosa LS, Mangueira C, Rosseto EA, Mota L, Oliveira AC, et al. Yellow fever revaccination during infliximab therapy. Arthritis Care Res (Hoboken). 2010;62(6):896-898. doi: 10.1002/acr.20045

40. Oliveira AC, Mota LM, Santos-Neto LL, Simões M, Martins-Filho OA, Tauil PL. Seroconversion in patients with rheumatic diseases treated with immunomodulators or immunosuppressants, who were inadvertently revaccinated against yellow fever. Arthritis Rheumatol. 2015;67(2):582-583. doi: 10.1002/art.38960

41. Bühler S, Jaeger VK, Eperon G, Furrer H, Fux CA, Jansen S, et al. Safety and immunogenicity of a primary yellow fever vaccination under low-dose methotrexate therapy – A prospective multi-centre pilot study. J Travel Med. 2020;27(6):taaa126. doi: 10.1093/jtm/taaa126

42. Papp KA, Haraoui B, Kumar D, Marshall JK, Bissonnette R, Bitton A, et al. Vaccination guidelines for patients with immunemediated disorders on immunosuppressive therapies. J Cutan Med Surg. 2019;23(1):50-74. doi: 10.1177/1203475418811335

43. Kimberlin DW, Barnett ED, Lynfield R (eds). Red book: 2021– 2024 report of the Committee on Infectious Diseases; 32nd ed. Itasca (IL):American Academy of Pediatrics;2021.

44. Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, et al.; Infectious Diseases Society of America. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-e100. doi: 10.1093/cid/cit684

45. Bugatti S, De Stefano L, Balduzzi S, Greco MI, Luvaro T, Cassaniti I, et al. Methotrexate and glucocorticoids, but not anticytokine therapy, impair the immunogenicity of a single dose of the BNT162b2 mRNA COVID-19 vaccine in patients with chronic inflammatory arthritis. Ann Rheum Dis. 2021;80(12):1635-1638. doi: 10.1136/annrheumdis-2021-220862

46. Chen YJ, Cheng PL, Huang WN, Chen HH, Chen HW, Chen JP, et al. Single-cell RNA sequencing to decipher the immunogenicity of ChAdOx1 nCoV-19/AZD1222 and mRNA-1273 vaccines in patients with autoimmune rheumatic diseases. Front Immunol. 2022;13:920865. doi: 10.3389/fimmu.2022.920865

47. Mahil SK, Bechman K, Raharja A, Domingo-Vila C, Baudry D, Brown MA, et al. The effect of methotrexate and targeted immunosuppression on humoral and cellular immune responses to the COVID-19 vaccine BNT162b2: A cohort study. Lancet Rheumatol. 2021;3(9):e627-e637. doi: 10.1016/S2665-9913(21)00212-5

48. Boekel L, Steenhuis M, Hooijberg F, Besten YR, van Kempen ZLE, Kummer LY, et al. Antibody development after COVID-19 vaccination in patients with autoimmune diseases in the Netherlands: A substudy of data from two prospective cohort studies. Lancet Rheumatol. 2021;3(11):e778-e788. doi: 10.1016/S2665- 9913(21)00222-8

49. Furer V, Eviatar T, Zisman D, Peleg H, Paran D, Levartovsky D, et al. Immunogenicity and safety of the BNT162b2 mRNA COVID-19 vaccine in adult patients with autoimmune inflammatory rheumatic diseases and in the general population: A multicentre study. Ann Rheum Dis. 2021;80(10):1330-1338. doi: 10.1136/annrheumdis-2021-220647

50. Haberman RH, Herati R, Simon D, Samanovic M, Blank RB, Tuen M, et al. Methotrexate hampers immunogenicity to BNT162b2 mRNA COVID-19 vaccine in immune-mediated inflammatory disease. Ann Rheum Dis. 2021;80(10):1339-1344. doi: 10.1136/annrheumdis-2021-220597

51. Braun-Moscovici Y, Kaplan M, Braun M, Markovits D, Giryes S, Toledano K, et al. Disease activity and humoral response in patients with inflammatory rheumatic diseases after two doses of the Pfizer mRNA vaccine against SARS-CoV-2. Ann Rheum Dis. 2021;80(10):1317-1321. doi: 10.1136/annrheumdis-2021-220503

52. Tzioufas AG, Bakasis AD, Goules AV, Bitzogli K, Cinoku II, Chatzis LG, et al. A prospective multicenter study assessing humoral immunogenicity and safety of the mRNA SARSCoV-2 vaccines in Greek patients with systemic autoimmune and autoinflammatory rheumatic diseases. J Autoimmun. 2021;125:102743. doi: 10.1016/j.jaut.2021.102743

53. Frommert LM, Arumahandi de Silva AN, Zernicke J, Scholz V, Braun T, Jeworowski LM, et al. Type of vaccine and immunosuppressive therapy but not diagnosis critically influence antibody response after COVID-19 vaccination in patients with rheumatic disease. RMD Open. 2022;8(2):e002650. doi: 10.1136/rmdopen-2022-002650

54. Krasselt M, Wagner U, Nguyen P, Pietsch C, Boldt A, Baerwald C, et al. Humoral and cellular response to COVID-19 vaccination in patients with autoimmune inflammatory rheumatic diseases under real-life conditions. Rheumatology (Oxford). 2022;61(SI2):SI180- SI188. doi: 10.1093/rheumatology/keac089

55. Feuchtenberger M, Kovacs MS, Eder A, Nigg A, Schäfer A. Methotrexate significantly reduces the humoral vaccination response against SARS-CoV-2 in older but not younger patients with rheumatoid arthritis. Rheumatol Int. 2022;42(6):959-966. doi: 10.1007/ s00296-022-05123-2

56. Arumahandi de Silva AN, Frommert LM, Albach FN, Klotsche J, Scholz V, Jeworowski LM, et al. Pausing methotrexate improves immunogenicity of COVID-19 vaccination in elderly patients with rheumatic diseases. Ann Rheum Dis. 2022;81(6):881-888. doi: 10.1136/annrheumdis-2021-221876

57. Benucci M, Damiani A, Infantino M, Manfredi M, Lari B, Grossi V, et al. Vaccination for SARS-CoV-2 in patients with psoriatic arthritis: Can therapy affect the immunological response? Front Med (Lausanne). 2022;9:811829. doi: 10.3389/fmed.2022.811829

58. Sugihara K, Wakiya R, Kameda T, Shimada H, Nakashima S, Kato M, et al. Humoral immune response against BNT162b2 mRNA COVID-19 vaccine in patients with rheumatic disease undergoing immunosuppressive therapy: A Japanese monocentric study. Medicine (Baltimore). 2022;101(42):e31288. doi: 10.1097/MD.0000000000031288

59. Nemeth D, Vago H, Tothfalusi L, Ulakcsai Z, Becker D, Szabo Z, et al. Factors influencing the SARS-CoV-2 infection and vaccination induced immune response in rheumatoid arthritis. Front Immunol. 2022;13:960001. doi: 10.3389/fimmu.2022.960001

60. Silva CA, Medeiros-Ribeiro AC, Kupa LVK, Yuki EFN, Pasoto SG, Saad CGS, et al. Immunogenicity decay and case incidence six months post Sinovac-CoronaVac vaccine in autoimmune rheumatic diseases patients. Nat Commun. 2022;13(1):5801. doi: 10.1038/s41467-022-33042-0

61. Aikawa NE, Kupa LVK, Medeiros-Ribeiro AC, Saad CGS, Yuki EFN, Pasoto SG, et al. Increment of immunogenicity after third dose of a homologous inactivated SARS-CoV-2 vaccine in a large population of patients with autoimmune rheumatic diseases. Ann Rheum Dis. 2022;81(7):1036-1043. doi: 10.1136/annrheumdis-2021-222096

62. Andreica I, Blazquez-Navarro A, Sokolar J, Anft M, Kiltz U, Pfaender S, et al. Different humoral but similar cellular responses of patients with autoimmune inflammatory rheumatic diseases under disease-modifying antirheumatic drugs after COVID-19 vaccination. RMD Open. 2022;8(2):e002293. doi: 10.1136/rmdopen-2022-002293

63. Mahil SK, Bechman K, Raharja A, Domingo-Vila C, Baudry D, Brown MA, et al. Humoral and cellular immunogenicity to a second dose of COVID-19 vaccine BNT162b2 in people receiving methotrexate or targeted immunosuppression: A longitudinal cohort study. Lancet Rheumatol. 2022;4(1):e42-e52. doi: 10.1016/S2665-9913(21)00333-7

64. Sieiro Santos C, Calleja Antolin S, Moriano Morales C, Garcia Herrero J, Diez Alvarez E, Ramos Ortega F, et al. Immune responses to mRNA vaccines against SARS-CoV-2 in patients with immune-mediated inflammatory rheumatic diseases. RMD Open. 2022;8(1):e001898. doi: 10.1136/rmdopen-2021-001898

65. Wroński J, Jaszczyk B, Roszkowski L, Felis-Giemza A, Bonek K, Kornatka A, et al. Humoral and cellular immunogenicity of COVID-19 booster dose vaccination in inflammatory arthritis patients. Front Immunol. 2022;13:1033804. doi: 10.3389/fimmu.2022.1033804

66. Wroński J, Jaszczyk B, Roszkowski L, Felis-Giemza A, Bonek K, Kornatka A, et al. The kinetics of humoral and cellular responses after the booster dose of COVID-19 vaccine in inflammatory arthritis patients. Viruses. 2023;15(3):620. doi: 10.3390/v15030620

67. Araujo CSR, Medeiros-Ribeiro AC, Saad CGS, Bonfiglioli KR, Domiciano DS, Shimabuco AY, et al. Two-week methotrexate discontinuation in patients with rheumatoid arthritis vaccinated with inactivated SARS-CoV-2 vaccine: A randomised clinical trial. Ann Rheum Dis. 2022;81(6):889-897. doi: 10.1136/annrheumdis-2021-221916

68. Abhishek A, Boyton RJ, Peckham N, McKnight Á, Coates LC, Bluett J, et al.; VROOM study investigators. Effect of a 2-week interruption in methotrexate treatment versus continued treatment on COVID-19 booster vaccine immunity in adults with inflammatory conditions (VROOM study): A randomised, open label, superiority trial. Lancet Respir Med. 2022;10(9):840-850. doi: 10.1016/S2213-2600(22)00186-2

69. Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, et al. American College of Rheumatology guidance for COVID-19 vaccination in patients with rheumatic and musculoskeletal diseases: Version 5. Arthritis Rheumatol. 2023;75(1):E1-E16. doi: 10.1002/art.42372

70. Syversen SW, Jyssum I, Tveter AT, Sexton J, Christensen IE, Tran TT, et al. Immunogenicity and safety of a three-dose SARSCoV-2 vaccination strategy in patients with immune-mediated inflammatory diseases on immunosuppressive therapy. RMD Open. 2022;8(2):e002417. doi: 10.1136/rmdopen-2022-002417

71. Connolly CM, Teles M, Frey S, Boyarsky BJ, Alejo JL, Werbel WA, et al. Booster-dose SARS-CoV-2 vaccination in patients with autoimmune disease: A case series. Ann Rheum Dis. 2022;81(2):291-293. doi: 10.1136/annrheumdis-2021-221206

72. Shirata M, Ito I, Tanaka M, Murata K, Murakami K, Ikeda H, et al. Impact of methotrexate on humoral and cellular immune responses to SARS-CoV-2 mRNA vaccine in patients with rheumatoid arthritis. Clin Exp Med. 2023;23(8):4707-4720. doi: 10.1007/s10238-023-01163-5

73. Durez P, Combe B. Should we stop methotrexate or not for vaccination? RMD Open. 2023;9(2):e002798. doi: 10.1136/rmdopen-2022-002798

74. Gary EN, Tursi NJ, Warner BM, Cuismano G, Connors J, Parzych EM, et al. Adenosine deaminase augments SARS-CoV-2 specific cellular and humoral responses in aged mouse models of immunization and challenge. Front Immunol. 2023;14:1138609. doi: 10.3389/fimmu.2023.1138609

75. Kremer JM, Lawrence DA, Hamilton R, McInnes IB. Long-term study of the impact of methotrexate on serum cytokines and lymphocyte subsets in patients with active rheumatoid arthritis: Correlation with pharmacokinetic measures. RMD Open. 2016;2(1): e000287. doi: 10.1136/rmdopen-2016-000287

76. Gerards AH, de Lathouder S, de Groot ER, Dijkmans BA, Aarden LA. Inhibition of cytokine production by methotrexate. Studies in healthy volunteers and patients with rheumatoid arthritis. Rheumatology. 2003;42(10):1189-1196. doi: 10.1093/rheumatology/keg323

77. Rudwaleit M, Yin Z, Siegert S, Grolms M, Radbruch A, Braun J, et al. Response to methotrexate in early rheumatoid arthritis is associated with a decrease of T cell derived tumour necrosis factor alpha, increase of interleukin 10, and predicted by the initial concentration of interleukin 4. Ann Rheum Dis. 2000;59(4):311- 3114. doi: 10.1136/ard.59.4.311

78. Bradley LM, Haynes L, Swain SL. IL-7: Maintaining T-cell memory and achieving homeostasis. Trends Immunol. 2005;26(3):172- 176. doi: 10.1016/j.it.2005.01.004

79. van Roon JA, Jacobs K, Verstappen S, Bijlsma J, Lafeber F. Reduction of serum interleukin 7 levels upon methotrexate therapy in early rheumatoid arthritis correlates with disease suppression. Ann Rheum Dis. 2008;67(7):1054-1055. doi: 10.1136/ard.2007.081059

80. Neurath MF, Hildner K, Becker C, Schlaak JF, Barbulescu K, Germann T, et al. Methotrexate specifically modulates cytokine production by T cells and macrophages in murine collageninduced arthritis (CIA): A mechanism for methotrexate-mediated immunosuppression. Clin Exp Immunol. 1999;115(1):42-55. doi: 10.1046/j.1365-2249.1999.00753.x

81. Glaesener S, Quách TD, Onken N, Weller-Heinemann F, Dressler F, Huppertz HI, et al. Distinct effects of methotrexate and etanercept on the B cell compartment in patients with juvenile idiopathic arthritis. Arthritis Rheumatol. 2014;66(9):2590-2600. doi: 10.1002/art.38736

82. Böhm I. Decrease of B-cells and autoantibodies after low-dose methotrexate. Biomed Pharmacother. 2003;57(7):278-281. doi: 10.1016/s0753-3322(03)00086-6

83. Nived P, Pettersson Å, Jönsson G, Bengtsson AA, Settergren B, Skattum L, et al. Methotrexate reduces circulating Th17 cells and impairs plasmablast and memory B cell expansions following pneumococcal conjugate immunization in RA patients. Sci Rep. 2021;11(1):9199. doi: 10.1038/s41598-021-88491-2

84. Park JK, Lee YJ, Bitoun S, Winthrop KL, Choi Y, Lee EB, et al. Interaction between B-cell activation factor and methotrexate impacts immunogenicity of seasonal influenza vaccination in patients with rheumatoid arthritis. Ann Rheum Dis. 2019;78(2):282-284. doi: 10.1136/annrheumdis-2018-214025

85. Elmér E, Nived P, Pettersson Å, Skattum L, Hellmark T, Kapetanovic MC, et al. Methotrexate treatment suppresses monocytes in nonresponders to pneumococcal conjugate vaccine in rheumatoid arthritis patients. J Immunol Res. 2022;2022:7561661. doi: 10.1155/2022/7561661

86. Wroński J, Ciechomska M, Kuca-Warnawin E. Impact of methotrexate treatment on vaccines immunogenicity in adult rheumatological patients – Lessons learned from the COVID-19 pandemic. Biomed Pharmacother. 2023;165:115254. doi: 10.1016/j.biopha.2023.115254