COVID-19 unlikely to ‘fade away’ for the immunocompromised: ‘It’s good to have options’
Click Here to Manage Email Alerts
COVID-19 fears and complications are likely to persist far into the future for immunocompromised individuals, a speaker noted at the Basic and Clinical Immunology for the Busy Clinician symposium.
“Things are ever-changing,” Cassandra Calabrese, DO, assistant professor of medicine in the department of rheumatic and immunologic disease and the department of infectious disease at the Cleveland Clinic Foundation, said of the pandemic.
Calabrese noted that there are “two pandemics,” one for the vaccinated and immunocompetent, and another for the unvaccinated and immunocompromised. “For our patients with immune-mediated diseases, COVID is not likely to fade away.”
The talk started with a basic plan for managing this patient population. The four-step process includes education; access to home COVID-19 testing; a clear plan for what to do in the event of actual exposure, possible exposure or symptoms; and a clinician on the other end of the phone who understands how the virus can impact the immunocompromised patient. “There are many layers to this,” she said.
Turning to therapeutic options, Calabrese highlighted just how “ever-changing” the pandemic has been using the example of the monoclonal antibody sotrovimab (Xevudy, GSK). The drug had enjoyed time as the mainstay of monoclonal antibody therapy, but between the time she submitted her slides and the presentation — just a few days — the situation had changed.
“Sotrovimab has fallen by the wayside due to a lack of efficacy against omicron subvariants,” she said. “Monoclonals targeting the spiked protein are subject to change depending on the variant of concern.”
Having said that, a novel compound, bebtelovimab (Eli Lilly & Co.) has shown efficacy against the omicron B.2 subvariant, according to Calabrese. “It is important to know what tools are in our toolbox to manage these high-risk patients,” she said.
Another possible tool for these patients is tixagevimab/cilgavimab (Evusheld, AstraZeneca), which is currently indicated for preexposure prophylaxis (PrEP). While the injection can offer protection from exposure for up to 6 months, Calabrese was clear about how this combination should be used. “Evusheld is not a substitute for a vaccine,” she said.
This combination may be used effectively in a number of immunocompromised populations, including those who are unlikely to mount sufficient antibody response from a vaccine, namely patients treated with B-cell depleting therapies and high-dose glucocorticoids.
Solid organ transplant recipients, CAR-T cell recipients, patients on active chemotherapy and those being treated with tyrosine kinase inhibitors may also benefit from Evusheld PrEP, according to Calabrese.
As for questions surrounding this therapy, access issues have arisen, along with concerns about utility against omicron subvariants. It is also uncertain whether another dose will be required after 6 months.
There may be better news for antiviral therapies, Calabrese said. “They have much less likelihood of escape from ability to neutralize the virus.”
The combination of nirmatrelvir/ritonavir (Paxlovid, Pfizer) can have as high as 80% effectiveness at preventing hospitalization or mortality if given within 3 to 5 days of symptom onset, according to Calabrese. “These are pretty impressive results.”
That said, this combination has “significant” drug-drug interactions with a number of commonly used therapies, including statins, steroids, anticoagulants and anti-arrhythmic medications. Accordingly, rheumatologists should use Paxlovid with caution.
Another antiviral option is molnupiravir (Merck). Calabrese acknowledged that it is “less effective” than Paxlovid. However, it does not have the same drug-drug interactions as its antiviral counterpart. “It is good to have options when treating high-risk patients,” she said.
Collapse
Calabrese C. Principles of outpatient management: “When IMID patient calls with possible COVID.” Presented at Basic and Clinical Immunology for the Busy Clinician; Feb. 26, 2022. (virtual meeting).
Read more about
Click Here to Manage Email Alerts