End of COVID emergency marks ‘less government effort,’ greater role for rheumatologists
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Communication between rheumatologists and patients with immune-mediated conditions will be essential for navigating COVID-19 in the endemic phase, according to a presenter at the Biologic Therapies Summit.
“The ending of the emergency protocols has moved COVID into our regular repertoire of bad things trying to kill us, as opposed to very bad things trying to kill us,” Cassandra Calabrese, DO, of the department of rheumatology and immunologic disease at the Cleveland Clinic, told attendees. “However, COVID is still here for our immunocompromised patients.”
Apart from the clinical issues immunocompromised individuals will experience with the virus itself, Calabrese stressed that there will be “less government effort” helping patients access testing and treatment.
“There will also be less data” to help guide rheumatologists in managing these patients, she added.
“Within patients with IMIDs, there are many different kinds of immunosuppression,” Calabrese said, adding that B-cell depleting therapies like rituximab (Rituxan, Genentech) create a different immunosuppressive profile than glucocorticoids or cyclosporine.
She noted that some experts have taken issue with the CDC definition of immunosuppression, for two key reasons.
“It is long and vague,” she said. “We have been critics of this definition from the start of the pandemic.”
Although Calabrese acknowledged that there are inherent challenges in defining the concept of immunosuppression because it can be so variable — particularly when solid organ transplant recipients, individuals with HIV and those with tumors are included — she highlighted real-world clinical implications of a poor definition.
“It is not doing anyone any favors in terms of triaging of who needs aggressive COVID-19 management,” she said. “It leaves people confused as to who is at highest risk. There is room to improve here in terms of patient education.”
According to Calabrese, a better way to think about risk is to consider the “layers” that may make a patient more susceptible to the virus, or at greater risk for severe outcomes. She suggested that age, comorbidities, vaccination status and B-cell depletion should all factor into a clinician’s assessment of any given immunosuppressed patient.
Regarding the care path, Calabrese said that for immunosuppressed patients with immune-mediated conditions, the rheumatologist should be heavily involved.
“Our patients have many different doctors and do not know who to call,” she said. “This is problematic.”
She then called on the rheumatology community to stay informed about the ever-changing treatment algorithms for the virus.
Although preexposure prophylaxis (PrEP) with monoclonal antibody products were useful for some patients earlier in the pandemic, no product is currently effective or available. That said, clinical trials of a novel product enrolling only immunocompromised individuals are underway.
“We are expecting to have this product available before the end of the year,” she said. “We are hopeful for that.”
Another treatment that “became interesting” throughout the pandemic was convalescent plasma. However, its efficacy remains unproven and there is no expectation that it will return to the armamentarium anytime soon.
There is better news for antiviral medications.
“They are really the only tool in our toolbox at the moment,” Calabrese said, noting that nirmatrelvir/ritonavir (Paxlovid, Pfizer) remains effective because of the design of the molecule.
“There is a time-sensitive window for Paxlovid,” she added. “It has to be given early.”
According to Calabrese, there are “many significant drug interactions that confuse or preclude” use of this medication. Attendees were encouraged to familiarize themselves with this profile.
Meanwhile, molnupiravir (Lagevrio, Merck) has not been tested as rigorously in immunocompromised patients but may have some use in the rheumatology space.
“It remains an option if Paxlovid is not feasible,” Calabrese said.
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Calabrese C. Optimal management of COVID-19 in the immunocompromised. Presented at: Biologic Therapies Summit X; May 11-13, 2023 (hybrid meeting).
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