Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors
Background Influenza vaccination (FV) is recommended for patients with cancer. Recent data suggested that the administration of the FV was associated with an increase in immune-related adverse events (irAEs) among patients on immune checkpoint inhibitors (ICIs). Myocarditis is an uncommon but seriou...
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2019-02-01
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| author | Anju Nohria Stephane Ederhy Franck Thuny Michael Mahmoudi Alexander R. Lyon Ryan J. Sullivan Javid J. Moslehi Justine V. Cohen Magid Awadalla Doll Lauren Alexandra Golden Syed S. Mahmood Raza M. Alvi Nathaniel D. Mercaldo Malek Z. O. Hassan Dahlia Banerji Adam Rokicki Connor Mulligan Sean P. T. Murphy Maeve Jones-O’Connor Lucie M. Heinzerling Merna Armanious Rongras Damrongwatanasuk Carol L. Chen Dipti Gupta Michael C. Kirchberger Sachin P. Shah Sarju Ganatra Paaladinesh Thavendiranathan Muhammad A. Rizvi Gagan Sahni Carlo G. Tocchetti Valentina Mercurio Donald P. Lawrence John D. Groarke Michael G. Fradley Kerry L. Reynolds Tomas G. Neilan |
| author_facet | Anju Nohria Stephane Ederhy Franck Thuny Michael Mahmoudi Alexander R. Lyon Ryan J. Sullivan Javid J. Moslehi Justine V. Cohen Magid Awadalla Doll Lauren Alexandra Golden Syed S. Mahmood Raza M. Alvi Nathaniel D. Mercaldo Malek Z. O. Hassan Dahlia Banerji Adam Rokicki Connor Mulligan Sean P. T. Murphy Maeve Jones-O’Connor Lucie M. Heinzerling Merna Armanious Rongras Damrongwatanasuk Carol L. Chen Dipti Gupta Michael C. Kirchberger Sachin P. Shah Sarju Ganatra Paaladinesh Thavendiranathan Muhammad A. Rizvi Gagan Sahni Carlo G. Tocchetti Valentina Mercurio Donald P. Lawrence John D. Groarke Michael G. Fradley Kerry L. Reynolds Tomas G. Neilan |
| author_sort | Anju Nohria |
| collection | DOAJ |
| description | Background Influenza vaccination (FV) is recommended for patients with cancer. Recent data suggested that the administration of the FV was associated with an increase in immune-related adverse events (irAEs) among patients on immune checkpoint inhibitors (ICIs). Myocarditis is an uncommon but serious complication of ICIs and may also result from infection with influenza. There are no data testing the relationship between FV and the development of myocarditis on ICIs.Methods Patients on ICIs who developed myocarditis (n = 101) (cases) were compared to ICI-treated patients (n = 201) without myocarditis (controls). A patient was defined as having the FV if they were administered the FV from 6 months prior to start of ICI to anytime during ICI therapy. Alternate thresholds for FV status were also tested. The primary comparison of interest was the rate of FV between cases and controls. Patients with myocarditis were followed for major adverse cardiac events (MACE), defined as the composite of cardiogenic shock, cardiac arrest, hemodynamically significant complete heart block and cardiovascular death.Results The FV was administered to 25% of the myocarditis cases compared to 40% of the non-myocarditis ICI-treated controls (p = 0.01). Similar findings of lower rates of FV administration were noted among myocarditis cases when alternate thresholds were tested. Among the myocarditis cases, those who were vaccinated had 3-fold lower troponin levels when compared to unvaccinated cases (FV vs. No FV: 0.12 [0.02, 0.47] vs. 0.40 [0.11, 1.26] ng/ml, p = 0.02). Within myocarditis cases, those administered the FV also had a lower rate of other irAEs when compared to unvaccinated cases (36 vs. 55% p = 0.10) including lower rates of pneumonitis (12 vs. 36%, p = 0.03). During follow-up (175 [IQR 89, 363] days), 47% of myocarditis cases experienced a MACE. Myocarditis cases who received the FV were at a lower risk of cumulative MACE when compared to unvaccinated cases (24 vs. 59%, p = 0.002).Conclusion The rate of FV among ICI-related myocarditis cases was lower than controls on ICIs who did not develop myocarditis. In those who developed myocarditis related to an ICI, there was less myocardial injury and a lower risk of MACE among those who were administered the FV. |
| format | Article |
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| institution | OA Journals |
| issn | 2051-1426 |
| language | English |
| publishDate | 2019-02-01 |
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| series | Journal for ImmunoTherapy of Cancer |
| spelling | doaj-art-23d13b13f69045c4aed81f89294aab8e2025-08-20T02:12:50ZengBMJ Publishing GroupJournal for ImmunoTherapy of Cancer2051-14262019-02-017110.1186/s40425-019-0535-yInfluenza vaccination and myocarditis among patients receiving immune checkpoint inhibitorsAnju Nohria0Stephane Ederhy1Franck Thuny2Michael Mahmoudi3Alexander R. Lyon4Ryan J. Sullivan5Javid J. Moslehi6Justine V. Cohen7Magid Awadalla8Doll Lauren Alexandra Golden9Syed S. Mahmood10Raza M. Alvi11Nathaniel D. Mercaldo12Malek Z. O. Hassan13Dahlia Banerji14Adam Rokicki15Connor Mulligan16Sean P. T. Murphy17Maeve Jones-O’Connor18Lucie M. Heinzerling19Merna Armanious20Rongras Damrongwatanasuk21Carol L. Chen22Dipti Gupta23Michael C. Kirchberger24Sachin P. Shah25Sarju Ganatra26Paaladinesh Thavendiranathan27Muhammad A. Rizvi28Gagan Sahni29Carlo G. Tocchetti30Valentina Mercurio31Donald P. Lawrence32John D. Groarke33Michael G. Fradley34Kerry L. Reynolds35Tomas G. Neilan36Aff17 0000 0004 0378 8294grid.62560.37Cardio-Oncology Program, Division of Cardiology, Department of MedicineBrigham and Women’s Hospital Boston MA USAAff15 Cardio-Oncology Program, Division of CardiologyHopitaux Universitaires est Paris Paris France1 Department of Cardiology, Unit of Heart Failure and Valvular Heart Diseases, Mediterranean University Cardio-Oncology Center (MEDI-CO Center), Hôpital Nord, Aix-Marseille I University, Marseille, FranceAff16 0000000103590315grid.123047.3Division of Cardiology, Department of MedicineSouthampton General Hospital Southampton UK1Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, LondonAff18 grid.32224.350000000403869924Massachusetts General Hospital Boston MA USAAff6 0000 0001 2264 7217grid.152326.1Vanderbilt School of Medicine 220 Pierce Ave 37232 Nashville TN USAAff3 0000 0004 0386 9924grid.32224.35Division of Oncology and Hematology, Department of MedicineMassachusetts General Hospital Boston MA USACardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USAAff2 0000 0000 8499 1112grid.413734.6Cardiology DivisionNew York-Presbyterian Hospital, Weill Cornell Medical Center New York NY USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USACardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USAAff4 Department of DermatologyUniversity Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU) Erlangen GermanyDivision of Cardiovascular Medicine, University of South Florida College of Medicine, Tampa, Florida, USAAff5 Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine Tampa FL USAAff6 0000 0001 2171 9952grid.51462.34Cardiology DivisionMemorial Sloan Kettering Cancer Center, Weill Cornell Medical College New York NY USACardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine, New York, New York, USAAff4 Department of DermatologyUniversity Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU) Erlangen GermanyAff8 grid.419182.7Cardiology DivisionLahey Hospital & Medical Center Burlington MA USADepartment of Cardiovascular Medicine, Lahey Clinic Medical Center, Burlington, Massachusetts, USAAff9 0000 0001 2157 2938grid.17063.33Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology Toronto General HospitalUniversity of Toronto Toronto Ontario CanadaAff10 0000 0004 0443 0913grid.413625.7Division of Oncology and Hematology, Department of MedicineLehigh Valley Hospital Allentown PA USACardiology Division, Mount Sinai Medical Center, New York, New York, USAAff13 0000 0001 0790 385Xgrid.4691.aDepartment of Translational Medical SciencesFederico II University Naples ItalyAff13 0000 0001 0790 385Xgrid.4691.aDepartment of Translational Medical SciencesFederico II University Naples ItalyAff3 0000 0004 0386 9924grid.32224.35Division of Oncology and Hematology, Department of MedicineMassachusetts General Hospital Boston MA USAAff17 0000 0004 0378 8294grid.62560.37Cardio-Oncology Program, Division of Cardiology, Department of MedicineBrigham and Women’s Hospital Boston MA USAAff5 Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine Tampa FL USAAff3 0000 0004 0386 9924grid.32224.35Division of Oncology and Hematology, Department of MedicineMassachusetts General Hospital Boston MA USAAff1 0000 0004 0386 9924grid.32224.35Cardiac MR PET CT Program, Department of RadiologyMassachusetts General Hospital 165 Cambridge Street, Suite 400 02114 Boston MA USABackground Influenza vaccination (FV) is recommended for patients with cancer. Recent data suggested that the administration of the FV was associated with an increase in immune-related adverse events (irAEs) among patients on immune checkpoint inhibitors (ICIs). Myocarditis is an uncommon but serious complication of ICIs and may also result from infection with influenza. There are no data testing the relationship between FV and the development of myocarditis on ICIs.Methods Patients on ICIs who developed myocarditis (n = 101) (cases) were compared to ICI-treated patients (n = 201) without myocarditis (controls). A patient was defined as having the FV if they were administered the FV from 6 months prior to start of ICI to anytime during ICI therapy. Alternate thresholds for FV status were also tested. The primary comparison of interest was the rate of FV between cases and controls. Patients with myocarditis were followed for major adverse cardiac events (MACE), defined as the composite of cardiogenic shock, cardiac arrest, hemodynamically significant complete heart block and cardiovascular death.Results The FV was administered to 25% of the myocarditis cases compared to 40% of the non-myocarditis ICI-treated controls (p = 0.01). Similar findings of lower rates of FV administration were noted among myocarditis cases when alternate thresholds were tested. Among the myocarditis cases, those who were vaccinated had 3-fold lower troponin levels when compared to unvaccinated cases (FV vs. No FV: 0.12 [0.02, 0.47] vs. 0.40 [0.11, 1.26] ng/ml, p = 0.02). Within myocarditis cases, those administered the FV also had a lower rate of other irAEs when compared to unvaccinated cases (36 vs. 55% p = 0.10) including lower rates of pneumonitis (12 vs. 36%, p = 0.03). During follow-up (175 [IQR 89, 363] days), 47% of myocarditis cases experienced a MACE. Myocarditis cases who received the FV were at a lower risk of cumulative MACE when compared to unvaccinated cases (24 vs. 59%, p = 0.002).Conclusion The rate of FV among ICI-related myocarditis cases was lower than controls on ICIs who did not develop myocarditis. In those who developed myocarditis related to an ICI, there was less myocardial injury and a lower risk of MACE among those who were administered the FV.https://jitc.bmj.com/content/7/1/53.full |
| spellingShingle | Anju Nohria Stephane Ederhy Franck Thuny Michael Mahmoudi Alexander R. Lyon Ryan J. Sullivan Javid J. Moslehi Justine V. Cohen Magid Awadalla Doll Lauren Alexandra Golden Syed S. Mahmood Raza M. Alvi Nathaniel D. Mercaldo Malek Z. O. Hassan Dahlia Banerji Adam Rokicki Connor Mulligan Sean P. T. Murphy Maeve Jones-O’Connor Lucie M. Heinzerling Merna Armanious Rongras Damrongwatanasuk Carol L. Chen Dipti Gupta Michael C. Kirchberger Sachin P. Shah Sarju Ganatra Paaladinesh Thavendiranathan Muhammad A. Rizvi Gagan Sahni Carlo G. Tocchetti Valentina Mercurio Donald P. Lawrence John D. Groarke Michael G. Fradley Kerry L. Reynolds Tomas G. Neilan Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors Journal for ImmunoTherapy of Cancer |
| title | Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors |
| title_full | Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors |
| title_fullStr | Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors |
| title_full_unstemmed | Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors |
| title_short | Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors |
| title_sort | influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors |
| url | https://jitc.bmj.com/content/7/1/53.full |
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