COVID-19 pandemic ‘still with us’ for patients with autoimmune, inflammatory diseases
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SCOTTSDALE, Ariz. — Although omicron variants appear generally less severe and more manageable than previous SARS-CoV-2 strains, patients with rheumatologic conditions should remain vigilant, according to a presenter.
“People think the pandemic is over,” Cassandra Calabrese, DO, of the department of rheumatology and immunologic disease at the Cleveland Clinic, told attendees at the Basic and Clinical Immunology for the Busy Clinician symposium. “It is not, particularly for our patients with autoimmune and inflammatory diseases.”
That said, Calabrese acknowledged that things are “getting better,” and that, moving forward, there will be “two epidemics” of COVID-19.
“One for the healthy and vaccinated, one for the unvaccinated and those with immune-mediated conditions,” she said.
According to Calabrese, rheumatologists should be able to educate patients with immune-mediated inflammatory diseases regarding the availability of preventative and therapeutic options.
“We envision an educated patient,” she said. “They need to know their risk, they need to have tests at home, they need to know who to call if they are exposed. We need to be able to link the person to the right care path.”
The first consideration is vaccination. Currently, Pfizer’s and Moderna’s bivalent vaccines, which offer protection to ancestral strains as well as omicron BA.4 and BA.5, are the only two options.
“Patients will get updated protection,” Calabrese said. “It is simplified now.”
However, she later acknowledged that the rapid mutation of the virus has proven challenging for the development of vaccines and monoclonal antibodies alike.
“Chasing variants has not panned out,” she said.
Meanwhile, patients with IMIDs have consistently shown a “waning” vaccine response, according to Calabrese.
“We should continue to boost our patients,” she said, adding that the protection conferred has been suboptimal.
As such, Calabrese argued that providers should be focusing on preventing severe COVID-19, rather than trying to prevent any infection at all.
Another consideration is — or rather was — monoclonal antibodies. Unfortunately, at the moment, there is a “desert” of options for these agents, according to Calabrese.
“Right now we have no monoclonals available,” she said. “But this will change.”
There is a small pipeline of products targeting omicron XBB and BQ1, which are the “heavily mutated” predominant circulating strains, Calabrese reported.
“A new product will be on the market soon, we hope,” she said.
There is better news for antivirals.
“This is a tool we currently do have in our toolbox,” she said. “They are excellent at preventing severe COVID in our patients.”
Combination therapy with nirmatrelvir/ritonavir (Paxlovid, Pfizer) at a 5-day course given within 5 days of symptom onset can reduce progression to severe disease, according to Calabrese. That said, she acknowledged significant drug-drug interactions with this product. These interactions should be reviewed by every rheumatologist prescribing this therapy, she added.
Molnupiravir (Lagevrio, Merck), meanwhile, is a “slightly less exciting option” due to lower efficacy than Paxlovid, Calabrese said. However, she encouraged attendees to consider it, as there are fewer drug-drug interactions.
“It is good to have options,” she said.
Another treatment option is convalescent plasma, which has been in use to varying degrees since the start of the pandemic.
“The results are variable,” Calabrese said. “It does appear to have effectiveness in preventing severe disease when given early in disease course [in the general population].”
For immunocompromised patients, convalescent plasma at high titers can prevent more severe disease if given at a later stage, according to Calabrese.
Lastly, Calabrese urged rheumatologists to consider the heterogeneity of their patient population.
“Not all immunosuppressed patients are the same,” she said.
For example, patients taking B-cell depleting therapies are at the highest risk for acquisition and severe infection, along with poor vaccine response. Rheumatologists should stay abreast of data associated with other drug classes like tumor necrosis factor inhibitors, in addition to their patients who have undergone transplant or have other types of immunosuppression.
“The pandemic is still with us, especially with our patients,” she said.
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Calabrese C. Rheumatologists: Vaccines, breakthrough and treatment. Presented at Basic and Clinical Immunology for the Busy Clinician, Feb. 25-26, 2023; Scottsdale, Arizona (hybrid meeting).
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