Navigating the Post-Pandemic Landscape: Continued COVID Management for Immunosuppressed Patients
By Cassandra Calabrese, DO
The COVID-19 pandemic has shifted dramatically since its peak, with many people believing the threat has subsided. However, for individuals with certain conditions, the risk of severe illness from COVID-19 remains high.
At the end of 2023, the U.S. Centers for Disease Control and Prevention reported that a staggering 87% of Americans aged 16 and older had been infected with SARS-CoV-2, and nearly 99% had evidence of both infection and vaccination. The World Health Organization declared COVID-19 no longer a pandemic threat, citing decreased morbidity and mortality. Yet, for those with compromised immune systems, the battle against COVID-19 is far from over.
For patients on B-cell-depleting therapies (BCDT), the risk of severe COVID-19 remains a critical concern. Research at Cleveland Clinic has shown that these patients are at significantly higher risk of hospitalization and death, even with Omicron variants known for their milder symptoms. This vulnerable population requires continued vigilance and support.
Staying Informed, Staying Safe
BCDT has been a powerful tool in managing rheumatologic and immune-mediated diseases for over 25 years, effectively reducing inflammation. However, it also diminishes natural immunity and blunts the COVID vaccine's effectiveness. Healthcare providers play a crucial role in keeping patients informed about these risks and offering guidance.
Patients on BCDT need to be aware of their ongoing vulnerability to severe COVID-19. We advise them to take precautions around sick individuals, consider masking in crowded places, and seek medical advice promptly when feeling unwell. Early antiviral treatment and pre-exposure prophylaxis (PrEP) can be life-saving for these patients.
Our 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 reinforces the importance of proactive treatment for these high-risk individuals.
COVID Vaccination and PrEP: A Balancing Act
While BCDT diminishes vaccine response, vaccination still offers some protection. We recommend scheduling vaccinations as close as possible to the most recent rituximab dose and two to four weeks before the next dose for optimal effectiveness.
PrEP, or pre-exposure prophylaxis, is another crucial tool in the arsenal against COVID-19 for high-risk individuals. The U.S. Food and Drug Administration has authorized pemivibart (Pemgarda®) for high-risk individuals, including those on BCDT. At Cleveland Clinic, we actively counsel and refer eligible patients for PrEP.
But here's where it gets controversial... Some argue that PrEP should be universally available, while others question its long-term effectiveness. What do you think? Share your thoughts in the comments below!
