One-week MTX holiday post-flu vax as good as two 

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Research presented at ACR 2022 found the shorter window reduced flare risk while retaining the same immune response. 

A one-week holiday from methotrexate may be better than a longer one after flu vaccination, as new research shows it reduces flares while maintaining immunogenicity. 

Current ACR guidelines recommend patients take a two-week break from MTX following their influenza vaccine. 

However, according to South Korean research presented at ACR Convergence 2022, antibody titre levels don’t appear to differ in rheumatoid arthritis patients who wait only one week to restart MTX after their flu vaccine compared to those who wait for two. And flares were less than half as likely in this group, the researchers found. 

“Patients and physicians alike do not often know what to do with methotrexate when a vaccination, including the annual flu vaccine or novel covid-19 vaccines, is required,” said lead author Dr Jin Kyun Park, of Seoul National University, in a statement. 

“It was relieving to find out that skipping methotrexate for one week is as effective as skipping it for two weeks to improve vaccine response with no increase in disease flare risk,” said Dr Park.  

In the prospective randomised parallel-group multi-centre non-inferiority trial, RA patients on a stable dose of MTX were randomly assigned to hold MTX for one week or two weeks after receiving the quadrivalent 2021–2022 seasonal influenza vaccine, with around 90 patients in each group. A control group of 62 people without autoimmune disease was included as a reference. 

The primary outcome was satisfactory vaccine response, defined as at least four-fold increase in antibody titres against two or more of the vaccine strains four weeks after vaccination. Secondary outcomes include positive response and antibody titres at four and 16 weeks after vaccination.  

The proportion of patients with a satisfactory vaccine response was similar in the one-week and two-week groups at week four and week 16, at around 70%, and responses for the control group were similar. 

“Temporarily discontinuing MTX for one week is non-inferior to MTX discontinuation for two weeks after vaccination to induce an immediate and long-term satisfactory vaccine response to a seasonal influenza vaccine in patients with RA on a stable dose of MTX,” the authors concluded. 

The research has also been published in Arthritis & Rheumatology, where it was noted that around 5% of patients in the one-week group experienced a flare in the first four weeks, compared to around 13% of the two-week group. 

Dr Park said it wasn’t clear yet whether holding methotrexate for one week improves response to other vaccines, and the next step is to see if the same approach can be applied to other DMARDs and vaccines. 

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