Points of View: COVID Vaccines in the Immunocompromised

Soiffer, Hematology/Oncology: The blood cancers have been the group of diseases, which are associated with the most immune compromised, and that's because the blood cancer itself may interfere with the immune system, but the therapies certainly are often immune suppressive and these include therapies that target B cells, therapies that target T cells. But, even small molecules that may, we think are directed for a particular disease, have off-target effects that affect T-cell and may affect viral immunity.

As solid tumor patients are being treated with more immune modulating agents and sometimes as a consequence of those immune modulating agents, they need to receive immune suppressive medications. They, too, are at risk for COVID, and perhaps more so than they would’ve been 10 years ago.

What we certainly don't want to do is take a step back from the potential lifesaving therapies that these medications represent. We want our patients to get these lifesaving medications and we don’t want to sell them short in their ability to be cured of their malignancy. That's why it’s so important that patients and their physicians take adequate precaution, so that they're able to be protected against COVID-19.

Calabrese, Rhematology: We've learned a lot about the impact of our immunosuppressive medications on the effectiveness of the COVID vaccine. So, I wouldn't say that any medicines need to be avoided, it's just that patients must be cautioned if they're on one of the medicines that we know will significantly dampen the response. And this is multifactorial, and age is a factor, but there are many drugs that we use that we know now very well really blunt the vaccine response.

The number one is Rituximab, or any drug that depletes B cells, we use a lot of Rituximab, neuro uses a lot of Rituximab and other B cell depleters to treat MS and other neuroinflammatory diseases. It is very unlikely that someone on these drugs will have any palpable response to COVID vaccines, and these are our highest-risk group. They have a tremendous risk of severe outcome if they get COVID, even if they're appropriately vaccinated and boosted. And this is a population we triage for tixagevimab-cilgavimab or EVUSHELD for pre-exposure prophylaxis.

Other groups that we consider to be more high risk in terms of not having responded great to their vaccines would be patients on high dose steroids like if they were on high dose steroids at the time they got vaccinated. Other drugs we use like mycophenolate, cyclophosphamide you know, probably Abatacepta of T-cell inhibitor. And then a variety of combinations and plus or minus other comorbidities can set the stage for vaccine non-response or lower response. Methotrexate doesn't seem to be a huge problem. There certainly are data that does blunt vaccine responses but that doesn't seem to be, at least on its own clinically significant in terms of increasing risk of severe outcomes like hospitalization and death.

TNF inhibitors that we use quite a bit of as do many other subspecialist who take care of patients with immune mediated inflammatory diseases also do not seem to be associated with the clinically significant reduced vaccine response. So we do by patient by patient basis, you know, based on what drug they're on have this shared informed decision making discussion about their vaccine response and then whether or not they need something like EVUSHELD And then again, the most important thing is that we have effective outpatient treatments including oral, antiviral and monoclonal antibody.

It's really important to let our patients know that or else they might not call us or even think to test themselves if they have COVID concerns as those treatments are all time sensitive but highly effective.

Patel, Allergy: There's not a lot of information on the timing of biologics and COVID vaccines. There are some expert recommendations and guidelines, but we just don’t have enough data yet to understand the immune response with particular biologics. If a patient who's immunocompromised or on immune-compromising agents or medications, including biologics, then it is recommended that if their disease permits, they should hold off on immunosuppressive medications for at least 1 to 2 weeks after getting the Covid vaccine.

Again, they should discuss with their a health care provider, and see whether that approach is right for them. It’s individualized. It’s whether their disease permits that type of temporary stopping.

The other thought is for a particular biologics, in particular one common rituximab for that particular biologic, the recommendation is to get it probably 2 to 4 weeks prior to COVID vaccine, if possible. These would be patients who are either on maintenance on an infrequent basis, or patients who are about to start.

For other immunosuppressive medications like anti-TNF-alpha antagonists, corticosteroids, there really is not enough data to make an educated decision about whether it’s important to time those type of biologics with COVID vaccine.

So for those medications, there's no recommendation on timing of the vaccine, but they should get the Covid vaccine as soon as possible.

It's important with the Covid vaccines to explain the risk and benefits to the patient and to understand what are the potential risks and side effects.

When the pandemic first started, there is a big interest in allergic reactions to COVID vaccine. And while that is a potential possibility, the risk for a COVID vaccine allergic reaction is actually really small for anaphylaxis. There is more of a risk of being struck by lightning than there is for having an anaphylactic reaction to a COVID vaccine. The most recent data for MRNA vaccines show allergic reactions are typically between one and five per million doses of COVID vaccine.

The other thing to understand is having a discussion risk-benefit ratio. How I conduct that in my practice is to talk about the benefits that COVID vaccine provides, which is, it does a really good job of preventing COVID hospitalization, death, and severe disease.

The most common side effects that I discuss with my patient are typically local side effects. So that would mean at the injection side. There's there can be pain, redness, swelling. And then there's a small minority. Patients get systemic side effects, so these would be things like chills, fever, muscle, pains, headaches.

There are reports of very rare side effects with COVID vaccine, and I do bring these up because I like for the patients to know. And again, this is an open conversation, and many patients know about some side effects from research on their own. We know that COVID vaccine has been associated with myocarditis in a minority of patients. It's extremely rare. ... But the conversation also should include that in one study, looking at patients with myocarditis, the majority of patients had mild to moderate disease, and they recovered without any intervention. And were normal afterwards.

There's also an association between blood clots and the specific J&J vaccine. We know that vaccine is no longer recommended in the US. So I think that's something that patients may bring to a provider to say, what do you think about these type of issues? ...

One of the things that we're fortunate about in health care is that to this date, the number one trusted source for a patient with regards to vaccines is still the health care provider. That's important. It's not social media. It's not the FDA or the CDC or Dr. Fauci. It's actually their health care provider. So we, as health care providers, have an important role in understanding and explaining and really advocating.

... It's important to give our strong opinion for vaccination, and that that is something that patients can really latch on to, and really trust the source that it's coming from.