Are you immunocompromised and feeling like COVID-19 is "over"? Think again. For some, the danger is far from gone, especially if you're undergoing B-cell-depleting therapy (BCDT). I'm Dr. Cassandra Calabrese, and I want to shed light on why continued vigilance is crucial for this specific group.
Let's face it: by the end of 2023, the CDC estimated that a whopping 87% of Americans aged 16 and up had antibodies against SARS-CoV-2 from infection, and nearly 99% had antibodies from a combination of infection and vaccination. Then, in January, the World Health Organization declared that COVID-19 was no longer a pandemic-level threat, citing a significant decline in overall illness and death.
These positive trends might lull you into a false sense of security. But here's where it gets controversial... not everyone benefits equally from this improved situation. Individuals with specific health conditions remain at high risk for serious complications from COVID-19. This is particularly true for those receiving BCDT for rheumatologic or other immune-mediated diseases – conditions where the immune system attacks the body. Think rheumatoid arthritis, lupus, or multiple sclerosis, to name a few.
At Cleveland Clinic, we've been actively researching COVID-19 and how different drug therapies impact our defenses against the virus since the pandemic began. Our research clearly shows that certain patient populations need ongoing monitoring, education, and early antiviral treatment. They may even benefit from pre-exposure prophylaxis (PrEP) – preventative medication taken before exposure to the virus.
Since the pandemic's onset, data has consistently demonstrated that patients on B-cell-depleting drugs face a significantly elevated risk of hospitalization and death from COVID-19. And this is the part most people miss... Even with the rise of Omicron variants, which are generally associated with milder symptoms in the general population, we continue to see this vulnerable group disproportionately affected by severe infections. Unfortunately, this heightened risk is likely to persist for the foreseeable future, meaning extra support is still necessary.
So, what can you do? Knowledge is power.
For over 25 years, BCDT has proven effective in reducing the auto-antibody response and inflammation that drive rheumatologic diseases. It works by targeting and depleting B cells, which are responsible for producing antibodies. But, and it's a big but, the very mechanism that alleviates symptoms also weakens natural immunity and reduces the effectiveness of COVID-19 vaccines.
If you're a healthcare provider caring for patients on BCDT, staying informed about current COVID-19 infection trends and recommendations for antivirals and PrEP is crucial. More importantly, you need to share this information with your patients. They need to understand that they remain vulnerable and at risk for hospitalization and death.
We advise patients on BCDT to exercise caution when around individuals who are sick. Consider wearing a mask in crowded settings like airplanes or public transportation. And most importantly, contact your healthcare provider immediately if you start feeling unwell. Early intervention is key for testing and treatment.
Our team recently published research (https://pubmed.ncbi.nlm.nih.gov/41132135/) highlighting the effectiveness of outpatient antiviral therapy for patients with immune-mediated diseases on B-cell-depleting agents. Our findings show that treatment with nirmatrelvir/ritonavir (Paxlovid) was associated with lower rates of hospitalization and death from the COVID-19 Omicron variant in this specific population. This reinforces the importance of prioritizing these patients for prompt treatment. For instance, a patient with rheumatoid arthritis on rituximab who develops a cough should be immediately considered for testing and, if positive, antiviral therapy.
We also provide guidance to BCDT patients on the timing of COVID-19 vaccines and boosters. While BCDT can blunt the vaccine response, vaccination still offers some protection. To maximize vaccine effectiveness, we recommend scheduling the vaccine administration as far as possible after the most recent rituximab dose and ideally two to four weeks before the next scheduled dose. This allows the immune system to mount a stronger response before being suppressed again.
Let's talk about PrEP: A potential shield.
The FDA has granted Emergency Use Authorization for pemivibart (Pemgarda®), a COVID-19 pre-exposure prophylaxis (PrEP), for individuals at high risk of developing serious illness. This monoclonal antibody treatment can provide passive immunity to help prevent infection. At Cleveland Clinic, we counsel high-risk patients, particularly those on B-cell-depleting therapies, about PrEP and refer them for treatment if appropriate. It's like giving your body a temporary boost of antibodies to fight off the virus.
The Takeaway:
While the overall COVID-19 situation has improved, it's vital to remember that immunocompromised individuals, especially those on BCDT, remain at significant risk. Continued vigilance, education, early antiviral treatment, and PrEP are essential for protecting this vulnerable population.
Now, I want to hear from you: Do you think public health messaging adequately addresses the ongoing risks for immunocompromised individuals? Should there be more targeted interventions for this group? Share your thoughts and experiences in the comments below! Let's start a conversation about how we can better protect those who are most vulnerable.
