Navigating the Evolving Landscape of COVID-19 Management for Immunosuppressed Patients
By Cassandra Calabrese, DO
The COVID-19 pandemic has been a global challenge, but as we move into 2024, the landscape is shifting. The U.S. Centers for Disease Control and Prevention reports that a staggering 87% of Americans aged 16 and older have developed antibodies to SARS-CoV-2, and nearly 99% have a combination of infection- and vaccine-induced antibodies. The World Health Organization declared COVID-19 no longer a pandemic threat, and overall morbidity and mortality have decreased.
However, this perceived reduction in danger doesn't apply to everyone. People with specific conditions, particularly those undergoing B-cell-depleting therapies (BCDT) for rheumatologic and immune-mediated diseases, remain at high risk for severe COVID-19 illness. At the Cleveland Clinic, we've been at the forefront of COVID-19 research since the pandemic began, focusing on understanding how certain therapies impact viral protection.
The Ongoing Risk for BCDT Patients
Data consistently shows that patients on BCDT face a significantly higher risk of hospitalization and death. Even with the Omicron variant, known for its generally milder symptoms, this vulnerable population remains disproportionately affected by severe infections. This highlights the need for continued vigilance and support for these patients.
Informing and Empowering Patients
BCDT effectively reduces auto-antibody response and inflammation, but it also diminishes natural immunity and weakens the COVID-19 vaccine response. Healthcare providers caring for BCDT patients must stay informed about COVID-19 trends, antiviral recommendations, and PrEP. It's crucial to share this information with patients, emphasizing their ongoing vulnerability to severe illness. We advise patients on BCDT to take precautions around sick individuals, wear masks in crowded places, and contact us promptly if they feel unwell for testing and treatment guidance.
Research Findings: Antiviral Therapy
Our recent research (https://pubmed.ncbi.nlm.nih.gov/41132135/) demonstrated the effectiveness of outpatient antiviral therapy with nirmatrelvir/ritonavir for patients with immune-mediated diseases on BCDT. The study showed significantly lower hospitalization and death rates from the Omicron variant in this specific population, reinforcing the importance of prioritizing these patients for treatment.
COVID-19 Vaccination and PrEP
While BCDT diminishes vaccine response, the COVID-19 vaccine still offers some protection. We recommend timing vaccine administration as long as possible after the most recent rituximab dose and two to four weeks before the next dose for optimal response. Additionally, we provide counseling and referrals for high-risk patients, particularly B-cell-depleted individuals, for COVID-19 pre-exposure prophylaxis (PrEP) through pemivibart (Pemgarda®).
