Navigating the Ongoing COVID-19 Landscape: Protecting the Immunocompromised
By Cassandra Calabrese, DO
The COVID-19 pandemic has evolved significantly since its inception, with a growing percentage of the population achieving immunity through infection and vaccination. However, for individuals with specific health conditions, the threat of severe illness from COVID-19 remains a pressing concern. This is particularly true for those undergoing B-cell-depleting therapies (BCDT) for rheumatological and other immune-mediated diseases.
At the Cleveland Clinic, our ongoing research since the pandemic's beginning has focused on understanding how certain drug therapies impact protection against COVID-19. We've identified key areas where continued vigilance and proactive measures are essential for vulnerable patient populations.
High-Risk Patient Groups Require Ongoing Attention
Data consistently demonstrates that patients on B-cell-depleting drugs face a significantly elevated risk of hospitalization and death from COVID-19. Even with the Omicron variant, known for its generally milder symptoms, this vulnerable group remains disproportionately affected by severe infections. This highlights the need for ongoing support and careful management for these patients.
Informing and Empowering Patients
BCDT has proven effective in reducing auto-antibody response and inflammation associated with rheumatological diseases. However, this mechanism also diminishes natural immunity and weakens the body's response to the COVID-19 vaccine. It's crucial for healthcare providers to stay informed about COVID-19 trends, antiviral recommendations, and PrEP options, and to communicate this information to patients.
Patients on BCDT need to understand their ongoing vulnerability to severe illness. We recommend they take precautions around sick individuals, consider wearing masks in crowded places like airplanes, and promptly contact us if they experience any symptoms. Early testing and treatment are vital for managing potential COVID-19 infections.
Research on Antiviral Therapy
Our recent research published in PubMed (https://pubmed.ncbi.nlm.nih.gov/41132135/) demonstrated the effectiveness of outpatient antiviral therapy with nirmatrelvir/ritonavir for patients with immune-mediated diseases on BCDT. This treatment significantly reduced hospitalization and death rates from the Omicron variant, reinforcing the importance of prioritizing these patients for antiviral therapy.
COVID-19 Vaccination and Boosters
While BCDT diminishes vaccine response, the COVID-19 vaccine still offers some protection. We advise patients on BCDT to receive the vaccine as soon as possible after their most recent rituximab dose and at least two to four weeks before the next dose. This timing maximizes the vaccine's effectiveness.
The Role of PrEP
The U.S. Food and Drug Administration has authorized the emergency use of pemivibart (Pemgarda®) as a pre-exposure prophylaxis (PrEP) for individuals at high risk of severe COVID-19 illness. At the Cleveland Clinic, we actively counsel high-risk patients, particularly those with B-cell depletion, and refer them for PrEP administration.
