Abstract

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.

Details

Title
Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors
Author
Awadalla, Magid  VIAFID ORCID Logo  ; Doll Lauren Alexandra Golden; Mahmood, Syed S; Alvi, Raza M; Mercaldo, Nathaniel D; Hassan, Malek Z O; Banerji, Dahlia; Rokicki, Adam; Mulligan, Connor; Murphy, Sean P T; Maeve Jones-O’Connor; Cohen, Justine V; Heinzerling, Lucie M; Armanious, Merna; Sullivan, Ryan J; Damrongwatanasuk, Rongras; Chen, Carol L; Gupta, Dipti; Kirchberger, Michael C; Moslehi, Javid J; Shah, Sachin P; Ganatra, Sarju; Thavendiranathan, Paaladinesh; Rizvi, Muhammad A; Sahni, Gagan; Lyon, Alexander R; Tocchetti, Carlo G; Mercurio, Valentina; Thuny, Franck; Ederhy, Stephane; Mahmoudi, Michael; Lawrence, Donald P; Groarke, John D; Nohria, Anju; Fradley, Michael G; Reynolds, Kerry L; Neilan, Tomas G
First page
53
Section
Research Article
Publication year
2019
Publication date
Feb 2019
Publisher
BMJ Publishing Group LTD
e-ISSN
20511426
Source type
Scholarly Journal
Language of publication
English
DOI
https://doi.org/10.1186/s40425-019-0535-y
ProQuest document ID
2638110542
Copyright
© 2019 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.