Ongoing COVID-19 Management for Individuals with Compromised Immune Systems
Written by Dr. Cassandra Calabrese (https://providers.clevelandclinic.org/provider/cassandra-calabrese/4267744)
As we approached the close of 2023, the Centers for Disease Control and Prevention (CDC) in the United States reported that approximately 87% of individuals aged 16 and above had developed antibodies against SARS-CoV-2 due to prior infections. Furthermore, nearly 99% of this demographic had either been infected or vaccinated, resulting in a combination of immunity. By January of the following year, the World Health Organization (WHO) announced that COVID-19 no longer posed a threat at pandemic levels, indicating a notable decline in both illness and death rates related to the virus.
These significant shifts in the COVID-19 scenario have led many to believe that the risks associated with the virus have diminished. However, it is crucial to recognize that certain groups of individuals remain particularly vulnerable to severe complications from COVID-19. This includes patients undergoing B-cell-depleting therapies (BCDT), which are commonly used to treat rheumatologic and other immune-related conditions.
At the Cleveland Clinic, we have been actively researching COVID-19 from the onset of the pandemic, focusing on how various drug treatments influence patient protection against the virus. Our findings suggest that specific patient populations necessitate ongoing attention and personalized guidance. Early intervention with antiviral medications can provide substantial benefits, and some patients may also be suitable candidates for pre-exposure prophylaxis (PrEP).
Data collected since the pandemic began consistently illustrate that individuals receiving B-cell-depleting therapies face significantly heightened risks of hospitalization and mortality. Even with the emergence of the Omicron variant, which has typically presented milder symptoms, we continue to observe that these patients are disproportionately affected by severe cases of COVID-19. This highlights the need for continued support and care for this high-risk group well into the future.
Patient Education and Guidance
For over 25 years, BCDT has proven effective in diminishing the auto-antibody responses and inflammation that characterize rheumatologic diseases. However, the very mechanisms that alleviate symptoms also compromise natural immunity and weaken the efficacy of COVID-19 vaccinations. Therefore, healthcare providers treating patients on BCDT must stay informed about the latest COVID-19 trends and recommended treatments, including antivirals and PrEP, and share this knowledge with their patients. It is vital for those on BCDT to understand that they remain at risk for severe illness and potential hospitalization. We advise our patients to take precautions when they are around individuals who are ill, consider wearing a mask in crowded places or on airplanes, and — crucially — to reach out to us if they experience any symptoms so we can guide them through testing and treatment options.
Our research team recently published findings (https://pubmed.ncbi.nlm.nih.gov/41132135/) regarding the effectiveness of outpatient antiviral therapies for immune-compromised patients taking B-cell-depleting drugs. We discovered that treatment with nirmatrelvir/ritonavir significantly correlated with reduced hospitalization and death rates due to the Omicron variant in this specific group, underscoring the necessity of prioritizing these patients for appropriate therapeutic interventions.
Additionally, we provide recommendations to BCDT patients regarding the timing of COVID-19 vaccinations and booster shots. While it is true that BCDT dampens the response to vaccines, receiving the vaccine still offers a degree of protection. The optimal timing for vaccination is to schedule it as far from the last rituximab dose as possible, ideally two to four weeks before the next dose, to enhance the vaccine's effectiveness.
A Note on Pre-Exposure Prophylaxis (PrEP)
The U.S. Food and Drug Administration (FDA) has recently renewed the Emergency Use Authorization for pemivibart (marketed as Pemgarda®), which serves as COVID-19 PrEP for those at elevated risk of severe illness. At the Cleveland Clinic, we offer counseling for high-risk patients, especially those receiving BCDT, and facilitate referrals for these individuals to obtain PrEP.
