Abstract
Background:
Sphingosine 1-phosphat receptor modulators (S1PRMs) have been linked to attenuated immune response to SARS-CoV-2 vaccines.
Objective:
To characterize differences in the immune response to SARS-CoV-2 vaccines in patients on selective versus unselective S1PRMs.
Methods:
Monocentric, longitudinal study on people with multiple sclerosis (pwMS) on fingolimod (FTY), siponimod (SIP), ozanimod (OZA), or without disease-modifying therapy (DMT) following primary and booster SARS-CoV-2 vaccination. Anti-SARS-CoV-2 antibodies and T-cell response was measured with electro-chemiluminescent immunoassay and interferon-γ release assay.
Results:
Primary vaccination induced a significant antibody response in pwMS without DMT while S1PRM patients exhibited reduced antibody titers. The lowest antibodies were found in patients on FTY, whereas patients on OZA and SIP presented significantly higher levels. Booster vaccinations induced increased antibody levels in untreated patients and comparable titers in patients on OZA and SIP, but no increase in FTY-treated patients. While untreated pwMS developed a T-cell response, patients on S1PRMs presented a diminished/absent response. Patients undergoing SARS-CoV-2 vaccination before onset of S1PRMs presented a preserved, although attenuated humoral response, while T-cellular response was blunted.
Conclusion:
Our data confirm differential effects of selective versus unselective S1PRMs on T- and B-cell response to SARS-CoV-2 vaccination and suggest association with S1PRM selectivity rather than lymphocyte redistribution.
Keywords: Multiple sclerosis, sphingosine 1-phosphate receptor modulators, disease-modifying therapies, T-cell response, B-cell response, SARS-CoV-2 vaccination
Introduction
Sphingosine 1-phosphate receptor modulators (S1PRMs) possess a unique mode of action as disease-modifying therapies (DMTs) for multiple sclerosis (MS). Since the approval of fingolimod (FTY) as the first in-class, non-selective S1PRM, more selective sphingosine 1-phosphate (S1P) agents have reached market authorization. The SARS-CoV-2 pandemic raised concerns about the impact of DMTs on vaccine response. For the vast majority of DMTs used in MS, an intact vaccine immune response could be demonstrated. Unfortunately, for B-cell–depleting therapies as well as for S1PRMs, a weakened humoral and cellular response was observed.1–3 However, previous studies were dominated by findings for FTY or S1P agents in general, while data on selective S1PRMs including siponimod (SIP), ozanimod (OZA), and ponesimod (PON) are limited.1–4 To date, the question remains if the attenuated immune response to SARS-CoV-2 vaccines represents a class specific effect of S1P agents or differs depending on sphingosine 1-phosphat receptor (S1PR) selectivity. Here, we aimed to determine and compare the humoral and cellular response after primary and booster SARS-CoV-2 vaccination in patients on FTY, OZA, and SIP compared to untreated people with multiple sclerosis (pwMS). In addition, we assessed whether the vaccine-elicited immune response remains preserved in patients who were vaccinated before S1PRM treatment initiation.
Material and methods
Patients and study approval
In our monocentric, longitudinal study, we included 256 pwMS, attending routine clinical care at the Multiple Sclerosis Center Dresden, Germany. Subgroups were selected according to their DMT status at the time of vaccination as treated with FTY (n = 143), SIP (n = 31), or OZA (n = 41) and without DMT (n = 41). Inclusion criteria were as follows: diagnosis of relapsing remitting (RR) MS, secondary progressive (SP) MS, or primary progressive (PP) MS and age ⩾18 years. Blood samples were drawn after completion of primary vaccination (first and second vaccination, T1) against SARS-CoV-2 with mRNA (BTN162b2, mRNA-1273) or viral vector vaccines (AZD122, Ad.26.COV2.S) and after first (third vaccination, T2) and second (fourth vaccination, T3) booster vaccinations with mRNA vaccines (BTN162b2, mRNA.1273), respectively. We excluded patients with administration of pre-exposure prophylaxis against COVID-19 and patients vaccinated with vector vaccine Ad.26.COV2.S only. The study was approved by the institutional review board of the University Hospital Dresden. Patients gave their written informed consent.
Detection of SARS-CoV-2–specific antibodies
IgG antibodies against SARS-CoV-2 spike protein receptor-binding domain (RBD) in serum samples were quantified via electrochemiluminescence immunoassay (ECLIA) on a COBAS e801 module (Roche, Basel, Switzerland). Seropositivity cut-off was defined as 0.8 U/mL as recommended by the manufacturer’s instructions. The lower detection limit was 0.43 U/mL; values below 0.43 U/mL were set to half the detection limit, that is, 0.215 U/mL. The upper detection limit was 25.000 U/mL; values above were set to 25.001 U/mL. The assigned unit U/mL corresponds to the World Health Organization (WHO) international standard binding antibody units (BAU)/mL.
Analysis of SARS-CoV-2–specific T-cell response
Lithium heparin blood samples were freshly prepared after collection. A SARS-CoV-2 QuantiFERON test (Qiagen, Hilden, Germany) was used to measure the interferon (IFN)-γ secretion of CD4+ and CD8+ T cells after stimulation with SARS-CoV-2 spike protein peptide pools antigen (Ag)1 and 2. Blood samples were incubated for 16–24 hours with SARS-CoV-2 peptide pools or with mitogen as positive control. IFN-γ release to the negative control of each sample was subtracted from responses to Ag1 and 2, respectively. Positivity cut-off was defined as 0.15 IU/mL. CD4+ T-cell IFN-γ release is defined by response to Ag1, and IFN-γ release to Ag2 demonstrates CD4+ and CD8+ T-cell response.
Statistical analysis
Normal distribution of data was visually assessed using quantile–quantile plots. Quantitative population characteristics were presented as measures of central tendency (mean value), followed by standard deviation (SD) or range. Data were analyzed applying Generalized Linear Mixed Models (GLMM) with linear link function for normally distributed data and γ distribution and log link function for right-skewed data. Model results are presented as mean value with 95% confidence interval (CI). Model estimates below zero were set to zero. Sex, age, Expanded Disability Status Scale (EDSS), time point, type of vaccination, confirmed previous COVID-19 infection, and DMT group served as fixed factors. p < 0.05 were considered as statistically significant. For pairwise comparisons, contrast tests with the Sidak correction were applied. Spearman’s correlation and partial correlations were used for assessment of correlations. For additional analyses, we applied a propensity score–based matching approach accounting for age and EDSS as covariates to create two subsets in a 2:1 ratio (FTY as comparator) to compare pwMS on FTY and SIP as well as on FTY and OZA excluding measurements with confirmed previous COVID-19 infection. Pairwise comparisons of total and subset lymphocyte counts as well as comparisons at baseline were performed with the Friedman tests, the Wilcoxon–Mann–Whitney U–tests, and chi-squared tests. Statistical analyses were performed using the IBM SPSS software (version 28.0, IBM Corporation, Armonk, NY, USA), and the data were visualized using GraphPad Prism (version 8; GraphPad Software, La Jolla, CA, USA).
Results
Patient characteristics
Demographic and clinical characteristics are presented in Table 1. The mean age of the overall study population was 49.0 (12.7) years (mean (SD)). Patients without DMT and patients on SIP were older as patients on OZA and FTY (p < 0.001 for comparisons between SIP and no DMT to FTY and OZA). Most of the patients (85.2%) were triple-vaccinated, while 9.4% received two doses of mRNA/viral vector vaccines and some patients had a combination of one (2.0%) or two (3.5%) vaccine doses and a status post COVID-19 infection. The primary immunization was completed with mRNA vaccines in most patients (84.1%). All patients who had a status post SARS-CoV-2 infection received one dose of an mRNA vaccine to complete the primary immunization (5.5%). All booster vaccinations were conducted with mRNA vaccines (BTN162b2, mRNA.1273). No significant difference between time to booster or time to blood collection following primary or booster vaccination was detected among the groups (Supplemental Table 1). An SARS-CoV-2 infection during the overall observation period was reported for 88 patients (34.2%).
Table 1.
Patient characteristics.
| All patients n = 256 |
No DMT n = 41 |
FTY n = 143 |
SIP n = 31 |
OZA n = 41 |
|
|---|---|---|---|---|---|
| Age, years (mean, SD) | 49.0 (12.7) | 58.2 (12.8) | 46.8 (10.5) | 59.9 (7.1) | 39.1 (11.3) |
| Female (n, %) | 168 (65.6%) | 33 (80.5%) | 89 (62.2%) | 19 (61.3%) | 27 (65.9%) |
| Disease duration, years (mean, SD) | 13.3 (8.2) | 16.1 (9.9) | 13.6 (6.4) | 18.7 (9.6) | 5.6 (4.9) |
| Disease course (n, %) | |||||
| RRMS | 205 (80.1%) | 23 (56.1%) | 139 (97.2%) | 0 (0%) | 41 (100%) |
| PPMS | 6 (2.3%) | 6 (14.6%) | 0 (0%) | 0 (0%) | 0 (0%) |
| SPMS | 45 (17.6%) | 12 (29.3%) | 4 (2.8%) | 31 (100%) | 0 (0%) |
| EDSS (mean, SD) | 3.4 (1.9) | 4.1 (1.9) | 3.0 (1.7) | 5.7 (1.5) | 2.4 (1.1) |
| Vaccination type (n, %) | |||||
| 2× mRNA/VVV | 24 (9.4%) | 5 (12.2%) | 15 (10.5%) | 1 (3.2%) | 3 (7.3%) |
| 3× mRNA/VVV | 218 (85.2%) | 33 (80.5%) | 122 (85.3%) | 29 (93.6%) | 34 (82.9%) |
| Infection + 1× mRNA/VVV | 5 (2.0%) | 1 (2.4%) | 3 (2.1%) | 0 (0%) | 1 (2.4%) |
| Infection + 2× mRNA/VVV | 9 (3.5%) | 2 (4.9%) | 3 (2.1%) | 1 (3.2%) | 3 (7.3%) |
| Treatment duration, days (mean, min–max) | 1728 (0–4689) | NA | 2356 (232–4689) | 718 (176–3008) | 303 (82–971) |
DMT: disease-modifying therapy; FTY: fingolimod; SIP: siponimod; OZA: ozanimod; SD: standard deviation; VVV: viral vector vaccines; NA: not applicable; RRMS: relapsing remitting multiple sclerosis; PPMS: primary progressive multiple sclerosis; SPMS: secondary progressive multiple sclerosis.
Humoral and cellular response to SARS-CoV-2 vaccination in pwMS with and without S1PR modulation
All patients without DMT mounted an anti-spike IgG response, while patients on S1PRMs exhibited an attenuated humoral response after completion of primary vaccination (Figure 1(a), T1). Patients on FTY (p < 0.001) and SIP (p < 0.05) showed significant lower antibody levels than patients without DMT. In contrast, no significant difference in mean antibody titer between patients on OZA and patients without DMT was observed. There were differences in seroconversion in the evaluated groups: 100% of patients without DMT and OZA versus 87% of patients on SIP and 82% of FTY reached level of seropositivity of antibody titer (Figure 1(d), T1).
Figure 1.
Humoral and cellular response to SARS-CoV-2 vaccination in pwMS with and without S1PR modulation. Anti-spike RBD IgG antibody (a) and (d) and T-cell response (b, c and e)–to SARS-CoV-2 vaccination in pwMS with and without S1PR modulation are depicted. Mean value with 95% CI (a)–(c) and proportion of patients (d) and (e) are presented for three time points: after primary vaccination (T1) with mRNA/viral vector vaccines, after booster 1 (T2) and booster 2 (T3) vaccinations with mRNA vaccines. Patients without DMT (black), FTY (orange), SIP (green), and OZA (blue) are presented. Cut-off lines (IFN-γ release to Ag1 and Ag2 < 0.15 IU/mL, anti-spike RBD IgG antibodies > 0.8 U/mL) are delineated (red, dotted line).
Following first and second booster vaccinations, mean antibody levels were similar in patients without DMT and patients on OZA (Figure 1(a), T2, T3). Although SIP patients presented significantly lower antibody levels than patients without DMT following first booster vaccination, no significant differences were found after the second booster dose (T2, p < 0.0001; T3, p < 0.05). 100% of patients without DMT, on OZA and SIP and 96% of patients on FTY seroconverted after first booster vaccination (Figure 1(d), T2). However, no increase of mean antibody titer was observed after first or second booster vaccination in patients on FTY. All pwMS without DMT developed a positive T-cell response, while the vast majority of patients on S1P agents failed to generate cellular immunity independent of S1PR agent used after primary vaccination (Figure1(b) and (c), T1). Only seven patients on S1PRMs (FTY n =4, OZA n = 3) presented SARS-CoV-2–specific T-cellular interferon (INF)-γ levels above the threshold of positive response after completion of primary vaccination (Figure 1(e), T1). A first booster vaccine dose induced a significant increase in SARS-CoV-2–specific T-cellular INF-γ levels in patients without treatment, while no further increase was observed following second vaccine boost (Figure 1(b) and (c), T2/T3). A positive T-cell response was detected only in eight (FTY n =2, OZA n = 6) and one (FTY n = 1) S1PR-modulated patients after first and second booster vaccinations, respectively (Figure 1(e), T2/T3).
Variables influencing vaccine response
A COVID-19 infection during the whole observation period was associated with significant higher post-vaccination mean antibody (p < 0.001) and INF-γ levels regardless of treatment (Ag1 p < 0.05, Ag2 p < 0.01). The severity of COVID-19 did not correlate with antibody level or T-cellular response, which was also confirmed with respect to the time between infection and assessment via partial correlations (Table 2). Higher age was significantly associated with lower IFN-γ levels to Ag1 (CD4+ T-cellular response, p < 0.05) while no effect of age on T-cellular response to Ag2 (CD4+ and CD8+ T-cellular response) or B-cell response could be determined. Both EDSS and vaccine type had no significant effect on humoral and cellular immune response.
Table 2.
SARS-CoV-2 infection.
| Categorization | All patients n = 256 |
No DMT n = 41 |
FTY n = 143 |
SIP n = 31 |
OZA n = 41 |
|---|---|---|---|---|---|
| SARS-CoV-2 infection (n, %) | 88 (34.4%) | 13 (31.7%) | 58 (40.6%) | 5 (16.1%) | 12 (29.3%) |
| Clinical records of details on SARS-CoV-2 infection available (n, %) | 65 (25.4%) | 11 (26.8%) | 41 (28.7%) | 5 (16.1%) | 8 (19.5%) |
| SARS-CoV-2 infection course (n, %) | |||||
| Asymptomatic | 4 (6.2%) | 0 (0%) | 3 (7.3%) | 1 (20%) | 0 (0%) |
| Mild | 44 (67.7%) | 9 (81.8%) | 29 (70.7%) | 3 (30%) | 3 (37.5%) |
| Moderate | 16 (24.6%) | 2 (18.2%) | 8 (19.5%) | 1 (20%) | 5 (62.5%) |
| Severe | 1 (1.5%) | 0 (0%) | 1 (2.4%) | 0 (0%) | 0 (0%) |
| Deathly | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) |
| Hospitalization (n, %) | 1 a (1.5%) | 0 (0%) | 1 a (2.4%) | 0 (0%) | 0 (0%) |
DMT: disease-modifying therapy; FTY: fingolimod; SIP; siponimod; OZA: ozanimod.
One patient needed to be hospitalized due to a severe SARS-CoV-2 infection. Intensive care was not necessary though.
SARS-CoV-2–specific immune response in propensity score–matched patients on different S1PR modulators
Since the age and EDSS was different among patients receiving different S1PR agents, we conducted a propensity score–matched analysis 2:1 with FTY as comparator in order to better distinguish differences among S1PR agents observed in the overall study population. After matching, 36 patients on FTY and 18 patients on SIP were included in subset 1. Compared to patients on FTY, patients on SIP showed significantly higher antibody levels (Figure 2(a), p < 0.05). 86.7% of SIP patients compared to 65.5% of FTY patients reached level of anti-spike RBD IgG seropositivity post primary vaccination (Figure 2(d), T1). The first booster induced an increase in antibody levels in FTY and in SIP patients (Figure 2(a), T2). 100% and 91.3% patients on SIP and FTY seroconverted after first booster dose (Figure 2(d), T2). Following a second booster vaccination, a further increase of antibody titers was detectable in SIP but not in FTY patients (Figure 2(a), T3). Neither patients on treatment with FTY nor SIP presented with positive cellular responses at any time point (Figure 2(b, c, e)).
Figure 2.
SARS-CoV-2–specific immune response in propensity score–matched patients on FTY and SIP. Anti-spike RBD IgG antibody (a) and (d) and T-cell response (b, c and e) are presented. A propensity score–matched analysis in a correlation 2:1 with FTY functioning as comparator is presented for FTY (n = 36) and SIP (n = 18). Mean values with 95% CI and proportion of patients (d) and (e) are presented for three time points: after primary vaccination (T1) with mRNA/viral vector vaccines, after booster 1 (T2) and booster 2 (T3) vaccinations with mRNA vaccines. Patients on FTY are labeled orange and on SIP green. Cut-off lines (IFN-γ release to Ag1 and Ag2 <0.15 IU/mL, anti-spike RBD IgG antibodies > 0.8 U/mL) are delineated (red, dotted line).
The propensity matched analysis comparing FTY to OZA consisted of 32 patients on FTY and 16 patients on OZA (subset 2). Antibody levels were significantly higher during OZA treatment (Figure 3(a), p = 0.001). Vaccination-induced anti-SARS-CoV-2–specific antibodies were observed in 80.8% of FTY and in 100% of OZA patients after completion of primary vaccination (Figure 3(d), T1). Following first booster vaccination, an increase in antibody levels could be observed both in FTY and OZA patients although the magnitude of response was more pronounced in OZA patients (Figure 3(a), T2). A seroconversion of 84.2% and 100% was observed in patients on FTY and OZA after first booster (Figure 3(d), T2). No further increase in antibody levels was detected following a second booster (Figure 3(a), T3). Mean IFN-γ release to Ag1 and Ag2 was below positivity cut-off in both groups (Figure 3(b)–(c)). A positive T-cell response was observed only in 7.7% of FTY and 8.3% of OZA patients after primary vaccination (Figure 3(e), T1). After first booster dose, none of the FTY and only 14.3% of the OZA patients presented a positive T-cellular response (Figure 3(e), T2). Only the CD19+ B-cell count was significantly higher in patients on SIP compared to patients on FTY at primary and first booster vaccination (Table 3). For patients on OZA significantly higher total lymphocyte, CD3+, CD3+CD4+, and CD19+ cell counts at primary vaccination and significantly higher CD3+CD4+ and CD19+ cell counts at booster vaccination were detected (Table 4). No significant differences in the time interval of blood collection after primary or booster vaccination or in the meantime to first booster vaccination was observed in both matched subsets (Supplemental Table 2).
Figure 3.
SARS-CoV-2–specific immune response in propensity score–matched patients on FTY and OZA. Anti-spike RBD IgG antibody (a) and (d) and T-cell response (b, c and e) are presented. A propensity score–matched analysis in a correlation 2:1 with FTY functioning as comparator is presented for FTY (n = 32) and OZA (n = 16). Mean values with 95% CI and proportion of patients (d) and (e) are presented for three time points: after primary vaccination (T1) with mRNA/viral vector vaccines, after booster 1 (T2) and booster 2 (T3) vaccinations with mRNA vaccines. Patients on FTY are labeled orange and on OZA blue. Cut-off lines (IFN-γ release to Ag1 and Ag2 < 0.15 IU/mL, anti-spike RBD IgG antibodies > 0.8 U/mL) are delineated (red, dotted line).
Table 3.
Lymphocyte counts at time points of vaccination FTY versus SIP.
| Treatment | Time point | Lymphocyte count (GPT/L) (mean, 95% CI) | CD3+ count (GPT/L) (mean, 95% CI) | CD4+ count (GPT/L) (mean, 95% CI) | CD8+ count (GPT/L) (mean, 95% CI) | CD19+ count (GPT/L) (mean, 95% CI) |
|---|---|---|---|---|---|---|
| FTY | ||||||
| n = 32 | First/second mRNA/VVV | 0.427 (0.345–0.508) | 0.199 (0.130–0.269) | 0.051 (0.008–0.094) | 0.142 (0.088–0.196) | 0.013 (0.010–0.016) |
| n = 24 | Third mRNA | 0.425 (0.298–0.553) | 0.208 (0.114–0.301) | 0.055 (0.008–0.102) | 0.154 (0.074–0.235) | 0.013 (0.007–0.020) |
| SIP | ||||||
| n = 17 | First/second mRNA/VVV | 0.360 (0.284–0.436) | 0.177 (0.111–0.242) | 0.051 (0.027–0.075) | 0.104 (0.056–0.152) | 0.020 (0.012–0.028) |
| n = 14 | Third mRNA/ | 0.424 (0.221–0.628) | 0.237 (0.082–0.392) | 0.080 (0.008–0.152) | 0.141 (0.048–0.233) | 0.042 (0.011–0.073) |
| p | First/second mRNA/VVV | 0.402 | 0.746 | 0.051 | 0.269 | <0.05 |
| Third mRNA | 0.802 | 0.762 | 0.059 | 0.452 | <0.001 | |
GPT/l: Gigaparticels per liter; FTY: fingolimod; SIP: siponimod; CI: confidence interval; VVV: viral vector vaccine.
Table 4.
Lymphocyte counts at time points of vaccination FTY versus OZA.
| Treatment | Time point | Lymphocyte count (GPT/L) (mean, 95% CI) | CD3+ count (GPT/L) (mean, 95% CI) | CD4+ count (GPT/L) (mean, 95% CI) | CD8+ count(GPT/L) (mean, 95% CI) | CD19+ count (GPT/L) (mean, 95% CI) |
|---|---|---|---|---|---|---|
| FTY | ||||||
| n = 32 | First/second mRNA/VVV | 0.420 (0.350–0.489) | 0.230 (0.172–0.288) | 0.045 (0.028–0.061) | 0.153 (0.115–0.192) | 0.018 (0.013–0.022) |
| n = 23 | Third mRNA | 0.412 (0.336–0.488) | 0.230 (0.165–0.295) | 0.046 (0.027–0.064) | 0.155 (0.112–0.199) | 0.014 (0.010–0.018) |
| OZA | ||||||
| n = 16 | First/second mRNA/VVV | 0.736 (0.480–0.992) | 0.492 (0.284–0.700) | 0.254 (0.129–0.379) | 0.210 (0.102–0.319) | 0.099 (0.038–0.160) |
| n = 10 | Third mRNA | 0.745 (0.310–1.180) | 0.496 (0.130–0.861) | 0.202 (0.010–0.395) | 0.266 (0.058–0.474) | 0.067 (0.027–0.108) |
| p | First/second mRNA/VVV | <0.05 | <0.05 | <0.001 | 0.638 | <0.001 |
| Third mRNA | 0.051 | 0.180 | <0.05 | 0.576 | <0.001 | |
GPT/l: Gigaparticels per liter; FTY: fingolimod; OZA: ozanimod; VVV: viral vector vaccine.
Before versus on treatment vaccination during S1PR treatment
A subgroup of patients was available that started on OZA, after primary vaccination against SARS-CoV-2 was already completed (n = 16). Evaluation of antibody and T-cellular response as well as booster vaccination was done afterwards when patients were on stable OZA therapy. Compared to patients who received vaccination after OZA start, antibody titers as well as T-cellular response were similar to patients who were vaccinated before treatment start. Seroconversion of 100% was observed both in patients vaccinated before starting OZA and in patients vaccinated on OZA. Additional vaccination presented a comparable response profile in both groups (Figure 4(a)–(e)). Neither the mean time between completing primary vaccination and booster vaccination to sample collection nor time interval between primary and booster vaccination did deviate significantly between patients vaccinated before or on OZA therapy (Supplemental Table 2).
Figure 4.
Humoral and cellular response to SARS-CoV-2 vaccination in patients before versus on treatment vaccination. Anti-spike RBD IgG antibody (a) and (d) and T-cell response (b, c and e) to SARS-CoV-2 vaccination in pwMS after primary vaccination before OZA start (n = 13, purple) and on OZA therapy (n = 13, blue) are presented. Mean values with 95% CI (a)–(c) and proportion of patients (d) and (e) are presented for two time points: after primary vaccination (T1) with mRNA/viral vector vaccines and after booster 1 (T2) vaccination with mRNA vaccines. Cut-off lines (IFN-γ release to Ag1 and Ag2 < 0.15 IU/mL, anti-spike RBD IgG antibodies > 0.8 U/mL) are delineated (red, dotted line).
Discussion
The COVID-19 pandemic raised several concerns about DMTs used in the treatment of MS. In this study, we aimed to differentiate the humoral and cellular response profile after primary and booster SARS-CoV-2 vaccination among selective (OZA, SIP) and unselective (FTY) S1PR agents. Our results align with previous studies showing attenuated humoral response to SARS-CoV-2 vaccination in patients on S1P agents compared to untreated MS control group following primary vaccination.1,4,5 However, there was a significant difference between different S1PR agents with the lowest antibody levels being observed in FTY patients. In patients on OZA, no significant difference in mean antibody titers compared to patients without DMT was measured. Noteworthy, seroconversion rate following primary vaccination was higher in patients on OZA and SIP than in patients on FTY as recently published. 6 First booster vaccination was found to elicit an increase in antibody levels in patients without DMT, while no further increase was observed after second booster dose. 7 Interestingly, in OZA and SIP patients, an increase in antibody titers up to levels comparable to untreated patients with a seroconversion rate of 100% was determined following first and second booster doses, respectively. Although we revealed a higher rate of seroconversion following first and second vaccine boosts in patients on FTY, no relevant increase in antibody levels was detected as reported.8,9 A correlation between antibody levels and protective immunity against SARS-CoV-2 infection has not been verified yet.10,11 FTY patients, classified as seropositive, but presenting very low antibody titers are likely to lack protective immunity. 12 The ability of these patients to mount an immune response, although attenuated, suggests that they may benefit from additional booster doses or distinct vaccine types. 13 In our propensity score–matched analysis, patients on either SIP or OZA exhibited significantly higher vaccine-induced antibody levels and seroconversion compared to patients on FTY confirming our main analyses and supporting findings from previous studies.6,8,14–16 Patients undergoing primary vaccination before start of OZA presented antibody titers comparable to patients vaccinated while on treatment. These findings implicate a preserved humoral response after S1PRM start. Heterogeneity in humoral response among S1P agents might be related to different S1PR affinities. While FTY acts on four of the five S1PR subtypes (S1PR1, 3, 4, 5), SIP and OZA exhibit a potent selectivity for S1PR1 and activity on S1PR5.17–19 Modulation on S1PR1, limiting lymphocyte egress from secondary lymphoid tissues, is associated with the predominant therapeutic effect of S1PRMs, but it is also supposed to be linked to diminished vaccine response. 17 Reduced antibody response in patients on S1P agents may be partially related to the role of S1PR1 on B-cells, too. 20 However, the impact on S1PR3 and S1PR4 may contribute to lower antibody titers following vaccination in patients on FTY as well.21–24 T-cell response has also been shown to be crucial for COVID-19 outcome and maintenance of SARS-CoV-2 immunity. 25 In concordance with other studies, we observed an intact T-cell response after primary vaccination in untreated pwMS, while cellular response was low or absent in patients on S1PRMs independent of S1P agent used.3,8,26 Following a booster dose, a significant increase in cellular response was observed in patients without DMT, while no relevant increase was detectable in patients on S1PRMs. In line with other reports, patients with previous SARS-CoV-2 infection had significantly increased antibody and T-cellular post-vaccination responses compared to patients without prior infection even in S1PR-modulated patients.9,26 Even in patients vaccinated before starting OZA therapy, a strongly reduced or absent cellular response comparable to patients vaccinated on treatment was noticeable. Assessment of T-cell response was performed after patients were on stable therapy, and lymphocytes were already trapped in lymphoid organs due to mode of action of OZA. Despite the strongly reduced T-cellular response in S1PR-modulated patients, the risk of more severe COVID-19 in patients receiving FTY and SIP is not increased over the general MS population. 27 It has been already hypothesized that although circulating T cells are reduced, the function and number of T cells in lymphoid organs might not be affected. 28 However, this assumption is contradictory to other assays based on IFN-γ release to measure T-cell immune response. 29 Whereas recall response to tetanus antigens was normal in a study with FTY-treated healthy volunteers, response to a novel antigen was impaired. 30 These findings were already discussed to indicate that T-cell response to novel antigens, like SARS-CoV-2, might be affected. 28 Furthermore, our hypothesis is contradicted by the fact that a positive T-cell response was observed 1-week post vaccination in 50% of patients vaccinated on SIP therapy. 16 These suggest that patients on S1PRM develop a T-cell response shortly after vaccination despite lymphocytopenia. In the patients of our propensity score–matched approach, we found a significant higher CD19+ cell count in SIP compared to FTY-treated patients, while for patients on OZA, a higher total lymphocyte as well as CD3+, CD3+CD4+, and CD19+ cell count was observed at vaccinations. Since patients on SIP and OZA mount significant higher antibody levels than patients on FTY immune response might be partially related to lymphocyte counts and its distribution. Previously, decrease in CD19+ B-cell count in FTY-treated patients has been linked to low response to SARS-CoV-2 booster dose. 31 Our data suggest that also differences in the T-cellular compartment may contribute to the differences in SARS-CoV-2 immune response after vaccination in pwMS using different S1PRMs. However, strategies allowing lymphocyte recovery to increase vaccine responses have to be critically discussed as FTY discontinuation is linked with disease reactivation. 32
In summary, our study consistently reveals a variable humoral response pattern among selective and unselective S1PRMs to SARS-CoV-2 vaccines. While SIP and OZA patients mount sufficient antibody titers and seroconversion after primary and booster vaccination, responses in FTY treated patients are relevantly decreased. T-cellular response is diminished or even absent independent of S1PRM and even when vaccination was started before S1PR modulation use. These data suggest relevant association between the mechanism of action of S1PR selectivity and response to SARS-CoV-2 vaccination but not lymphocyte redistribution in general. However, the clinical relevance of these data including risk profiles for severe SARS-CoV-2 infections after vaccination is still unclear.
Supplemental Material
Supplemental material, sj-docx-1-msj-10.1177_13524585231200719 for Differential effects of selective versus unselective sphingosine 1-phosphate receptor modulators on T- and B-cell response to SARS-CoV-2 vaccination by Undine Proschmann, Magdalena Mueller-Enz, Christina Woopen, Georges Katoul Al Rahbani, Rocco Haase, Anja Dillenseger, Marie Dunsche, Yassin Atta, Tjalf Ziemssen and Katja Akgün in Multiple Sclerosis Journal
Acknowledgments
The authors thank Michaela Marggraf, Andrea Brandis, Stefanie Bodach, Nicole Heubner, and Robin Blakowski (Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus Dresden, Technical University of Dresden, Dresden, Germany) for excellent technical support.
Footnotes
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: U.P. received speaker fee from Merck, Biogen, Bayer, and Roche and personal compensation from Biogen, Roche, and Sanofi for consulting service. C.W. received travel support from Novartis. A.D. received personal compensation and travel grants from Sanofi-Aventis, Janssen-Cilag, Biogen, Celgene/Bristol-Myers Squibb, and Roche for speaker activity. T.Z. reports consulting or serving on speaker bureaus for Biogen, Celgene, Roche, Novartis, Celgene Merck, and Sanofi as well as research support from Biogen, Novartis, Merck, and Sanofi. K.A. received personal compensation from Roche, Sanofi, Alexion, Teva, Biogen, and Celgene for consulting service. M.M.-E., G.K.A.R., R.H., M.D., and Y.A. have nothing to disclose.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was partially funded by Bristol-Myers Squibb.
ORCID iDs: Christina Woopen 
https://orcid.org/0000-0002-7896-8682
Georges Katoul Al Rahbani
https://orcid.org/0000-0002-2969-0717
Tjalf Ziemssen
https://orcid.org/0000-0001-8799-8202
Supplemental material: Supplemental material for this article is available online.
Contributor Information
Undine Proschmann, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Magdalena Mueller-Enz, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Christina Woopen, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Georges Katoul Al Rahbani, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Rocco Haase, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Anja Dillenseger, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Marie Dunsche, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Yassin Atta, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Tjalf Ziemssen, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
Katja Akgün, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
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Supplementary Materials
Supplemental material, sj-docx-1-msj-10.1177_13524585231200719 for Differential effects of selective versus unselective sphingosine 1-phosphate receptor modulators on T- and B-cell response to SARS-CoV-2 vaccination by Undine Proschmann, Magdalena Mueller-Enz, Christina Woopen, Georges Katoul Al Rahbani, Rocco Haase, Anja Dillenseger, Marie Dunsche, Yassin Atta, Tjalf Ziemssen and Katja Akgün in Multiple Sclerosis Journal