Navigating the Evolving COVID Landscape: Ongoing Care for Immunosuppressed Patients
By Cassandra Calabrese, DO
As we approach the end of 2023, the COVID-19 pandemic has significantly transformed. The U.S. Centers for Disease Control and Prevention reports that a staggering 87% of Americans aged 16 and above have developed SARS-CoV-2 antibodies, with nearly 99% showing evidence of both infection and vaccination. The World Health Organization declared COVID-19 no longer a pandemic threat, citing a substantial decline in morbidity and mortality. However, this shift in the landscape has led some to underestimate the risks associated with the virus.
Despite the overall improvement, individuals with specific conditions remain highly susceptible to severe COVID-19 complications, particularly those undergoing B-cell-depleting therapies (BCDT) for rheumatological and immune-related ailments. At the Cleveland Clinic, our ongoing research since the pandemic's inception has shed light on the unique challenges faced by these patients.
The Ongoing Threat for Immunosuppressed Patients
Our studies reveal that patients on BCDT face a significantly elevated risk of hospitalization and mortality, even with the Omicron variants known for their milder symptoms. This vulnerable group continues to experience severe infections disproportionately, necessitating continued support and vigilance.
Informing and Empowering Patients
BCDT has proven effective in managing rheumatological diseases by reducing auto-antibody response and inflammation. However, this mechanism also diminishes natural immunity and weakens the COVID-19 vaccine's effectiveness. Healthcare providers must stay informed about COVID-19 trends, antiviral recommendations, and PrEP. Patients need to understand their ongoing vulnerability and the potential for hospitalization and death. We advise BCDT patients to take precautions around sick individuals, wear masks in crowded places, and promptly contact us for testing and treatment guidance.
Research Insights: Antiviral Therapy and PrEP
Our recent research highlights the effectiveness of outpatient antiviral therapy with nirmatrelvir/ritonavir for patients on BCDT, demonstrating reduced hospitalization and death rates from the Omicron variant. This finding underscores the importance of prioritizing these patients for treatment.
Additionally, we provide guidance on COVID-19 vaccination and booster timing for BCDT patients. While the vaccine's effectiveness is diminished, it still offers some protection. Administering the vaccine as soon as possible after the most recent rituximab dose and two to four weeks before the next dose optimizes vaccine response.
PrEP: A Powerful Tool
The U.S. Food and Drug Administration has authorized pemivibart (Pemgarda®) as a pre-exposure prophylaxis (PrEP) for high-risk individuals, including those on BCDT. At the Cleveland Clinic, we actively counsel and refer eligible patients to receive PrEP, empowering them with an additional layer of protection against severe COVID-19 outcomes.
