‘Who do they call?’: Patient, provider education crucial for managing outpatient COVID-19
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Pre- and post-exposure prophylaxis will be critical in managing outpatient COVID-19 infection in patients with immune-mediated conditions, according to speakers at ACR Convergence 2021.
In a joint presentation, Cassandra Calabrese, DO, director of the Rheumatology-Infectious Disease Clinic and training program at the Cleveland Clinic, and Leonard H. Calabrese, DO, director of the RJ Fasenmyer Center for Clinical Immunology at the Cleveland Clinic, discussed the importance of education in patients with rheumatic diseases dwelling in the community.
Leonard Calabrese pulled the lens out to the “30,000-foot view” of the pandemic, noting that the flood of studies on COVID topics largely focuses on two areas: epidemiology and severe outcomes, such as hospitalization and death. There are fewer studies on patients with mild or moderate disease.
“We have scores and scores of data,” he said. “What we do not focus on, as a profession, is how our patients with immune-mediated diseases should be managed for outpatient COVID.”
Many patients may be out in the community, either unvaccinated or vaccinated with an incomplete immune response, who are at risk for the infection, he said.
“If they develop a fever, a runny nose and a headache, how attuned are they that they may have COVID?” he asked. “And if they do have COVID, who do they call? Do they call their primary care doctor, or do they call you?”
Education of these patients is critical because their condition and its treatments may put them at risk for acquisition and severe outcomes, and they may have an insufficient vaccine response, according to Leonard Calabrese. Perhaps more important is that these patients should understand which of their providers is most knowledgeable about the “care pathway” for their particular case, he said.
“There are different layers to outpatient management being a success,” Cassandra Calabrese said. “There is an educated patient and an educated provider. Both components are lacking right now.”
Poor communication is one issue. Lack of resources is another. Yet a third is that accessing antiviral treatments and monoclonal therapies in the pre- or post-exposure setting may vary from health system to health system. “That is why it is so important to take a few moments to go over this with your patients so they know what to do,” she said.
Medications are on the way. For patients who have been exposed, there are currently two FDA-approved monoclonal agents available: casirivimab/imdevimab (REGEN-COV, Regeneron) and bamlanivimab/etesevimab (Eli Lilly).
“This is actually infusing them with the anti-spike antibody and has a very high level of efficiency,” Leonard Calabrese said. He added that it is important for rheumatologists to have “declarative knowledge” about the drugs themselves and “procedural knowledge” about how to access them.
The final piece of the puzzle pertains to pre-exposure prophylaxis, or PrEP. The AstraZeneca product AZD7442 has moved rapidly through the clinical trial process.
The data are “unbelievably impressive,” showing reduced incidence of infection, Leonard Calabrese said. “The pharmacokinetics and pharmacodynamics suggest that it could be an intramuscular shot once every 6 months.”
For patients with immune-mediated conditions, or who are being treated with a drug such as rituximab (Rituxan, Genentech), this is a game changer, according to Cassandra Calabrese.
“We think the monoclonals as PrEP is going to be huge,” she said. “The AstraZeneca product is really impressive and really important for this special patient population that we have.”
Emergency use authorization is pending within weeks, she said.
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Calabrese C, et al. Abstract #6S202. Presented at: ACR Convergence 2021; November 5-9, 2021 (virtual meeting).
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