Rituximab impairs immunoglobulin ( Ig)M and IgG (subclass) responses after influenza vaccination in rheumatoid arthritis patients

Summary Rituximab ( RTX ) treatment in rheumatoid arthritis ( RA ) patients severely hampers humoral response after influenza vaccination as determined by haemagglutination inhibition assay ( HI ). It is not known whether HI reflects both immunoglobulin ( Ig)M and IgG (subclass) influenza response, and whether IgM antibodies contribute to the low rate of influenza infection seen in RA patients. Twenty RA patients on methotrexate ( MTX ), 23 on RTX and 28 healthy controls ( HC ) received trivalent influenza subunit vaccination. Before and 28 days after vaccination, H 1 N 1‐ and H 3 N 2‐specific antibodies were measured by HI and by IgM and IgG (subclass) enzyme‐linked immunosorbent assay ( ELISA ). B cell activating factor (BAFF ) levels were determined in serum samples before vaccination. Vaccination induced a significant increase of IgM and IgG ( IgG 1 and IgG 3) antibodies against both strains in the HC and MTX groups (all P  < 0·01), but not in the RTX group. HI correlated significantly in all cases with IgG ( IgG 1) but not with IgM . In RTX late patients ( RTX treatment 6–10 months before vaccination), IgG ( IgG 1 and IgG 3) response to vaccination was restored, but not IgM response. BAFF levels were significantly increased in RA‐RTX patients and correlated with total IgG levels. Haemagglutination inhibition assay, used as gold standard, detects primarily IgG ( IgG 1) responses. IgM‐ and IgG influenza‐specific antibodies increase after vaccination in HC and RA patients except in patients on RTX treatment. BAFF levels are increased in both early and late RTX ‐treated patients, but do not correlate with an influenza‐specific antibody response.