METHOTREXATE delay for 1 month after 13 valent pneumococcal conjugate vaccination did not worsen rheumatoid arthritis disease control, structural progression, or treatment escalation over 1 year, according to an ancillary analysis of the VACIMRA trial.
The original VACIMRA trial showed that postponing methotrexate initiation for 1 month after PCV13 improved humoral vaccine responses at 1 and 12 months. This follow up analysis addressed a clinically important question for rheumatologists: whether that short delay compromises the early treatment window in patients with rheumatoid arthritis.
The ancillary study compared patients with early rheumatoid arthritis who began methotrexate immediately with those who started methotrexate 1 month after vaccination. Investigators assessed changes in DAS28 ESR from inclusion to Months 1, 2, 3, 6, and 12. Radiographic progression was evaluated using the van der Heijde modified Sharp score on X rays at inclusion, Month 6, and Month 12.
Similar Remission and Radiographic Outcomes
Among 276 VACIMRA participants, 100 were enrolled at the Montpellier center. Of these, 96 were analyzable at baseline and 83 at Month 12. Baseline characteristics were similar between groups, including a mean age of 58 years, baseline DAS28 ESR of 4.88, and total modified Sharp score of 1.53.
At 12 months, remission rates were comparable between immediate and delayed methotrexate initiation groups, at 53.7% versus 46.3%, respectively. Rates of low disease activity were also not significantly different, at 75.6% versus 61.0%. DAS28 ESR scores were similar at Months 1 and 3, but favored the delay group at Month 6 and Month 12.
Structural outcomes were reassuring. Modified Sharp score progression was comparable at both Month 6 and Month 12, suggesting that short term methotrexate delay after PCV13 did not translate into greater radiographic damage during the first year.
Implications for Vaccination Timing
The findings support the possibility of aligning early rheumatoid arthritis treatment with vaccine optimization in selected patients. For clinicians, the key message is that a 1 month methotrexate delay after PCV13 improved vaccine response in the parent trial without worsening disease activity, radiographic progression, or the need for treatment escalation over 1 year.
The authors concluded that deferring methotrexate initiation for 1 month after PCV13 may be a viable strategy to enhance immunity without undermining early rheumatoid arthritis outcomes.
Reference
Than T et al. One-month delay in methotrexate initiation on rheumatoid arthritis outcomes: One-year ancillary analysis of the VACIMRA trial. Rheumatology (Oxford). 2026;DOI: 10.1093/rheumatology/keag270.
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