Leonard Calabrese, DO, on COVID-19 and the Immunocompromised Patient

If a patient is immunocompromised or has a weakened immune system, or lives with someone who does, it is imperative to create a COVID-19 action plan, Leonard Calabrese, DO, said during his presentation at the Interdisciplinary Autoimmune Summit (IAS) virtual session.

Dr Calabrese is a professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and the vice chair of the department of Rheumatic and Immunologic diseases. Dr Calabrese is also the director of the RJ Fasenmyer Center for Clinical Immunology specializing in diseases of the immune system, at the Cleveland Clinic, in Cleveland, Ohio.

The plan may include basic steps such as “getting an updated COVID-19 vaccine, improving ventilation and spending time outdoors when possible, getting tested promptly if you have been exposed or experience symptoms, washing hands often, and finally, wearing a well-fitting respirator or mask and maintain distance in crowded spaces,” Dr Calabrese said during his presentation, in which he focused on the prevention and treatment of COVID-19 among patients who suffer from a weak or compromised immune system.

The course of COVID-19 infection is characterized by 2 or 3 stages, Dr Calabrese noted. “Understanding the prospects of treating the severe phase of the illness with immunotherapy is important,” he said. Even if the immunopathogenesis remains unclear, some treatments show promise.

Circling back to the stages of COVID-19 infection, Dr Calabrese said, “Most patients who recover experience 2 stages of illness commencing with an asymptomatic incubation period, followed by a nonsevere symptomatic illness lasting for several weeks, occurring in about 80% of those infected. In the remainder, a third phase marked by a severe respiratory illness, often accompanied by multisystem dysfunction, coagulopathy, and shock is observed.” This phase of illness, he said, is characterized by hypercytokinemic inflammation and is often referred to as cytokine storm.

Patients who are immunocompromised make up 3% of the population in United States. Additionally, an even larger group of people have become infected with COVID-19 despite being vaccinated.

“Immunocompromised patients are people whose immune system is weakened either because of underlying health conditions, such as patients who are receiving active treatment for blood cancers, advanced or untreated HIV infection, or taking immunosuppressive therapies,” Dr Calabrese explained. Immunocompromised patients are unable to actively fight the virus, not to forget the various mutating virus strains. An extra layer of protection in the form of vaccine becomes essential and hugely helpful to those with a weakened immune system.

When assessing a patient’s level of immune compromise, Dr Calabrese recommended considering the disease severity, the duration of the sickness, clinical stability, risk of complications, comorbidities, and any potential immune-suppressing treatment. In cases like these, a patient’s primary health care provider, in consultation with other specialists, may be in the best position to determine the patient’s level of immune compromise.

A prospective cohort study published in the Annals of Internal Medicine coauthored by Deepak Parakkal, MBBS, MS, et al, found that compared to nonusers, patients with chronic inflammatory disease were reported to have a lower COVID-19 vaccine-induced antibody response when treated with glucocorticoids and B-cell depletion therapy. All 133 patients with chronic inflammatory diseases and 53 healthy subjects received 2 doses of mRNA vaccine against SARS-CoV-2.  

Another observational study investigating the immunogenicity of SARS-CoV-2 mRNA vaccines in adults with inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, or psoriatic disease, with or without maintenance immunosuppressive therapies, found the warranted need for “a third dose of the mRNA vaccine and for continued monitoring of immunity in these patient groups,” Dr Calabrese said.

So, what is the overall strategy to protect and treat the immunocompromised patient? “Educating the patient, granting unconditional access to home testing, calling the right health care practitioner, and finding the right care path,” Dr Calabrese summarized.

Patient education results in self-awareness of the infection, in turn creating time sensitivity for early diagnosis and access to procedural knowledge. The definition of the right care provider may change from patient to patient. It could be a physician, or an advanced practitioner, or a specialist in transplant or oncology. Regardless of who it is, “whoever has the right path for you is your optimal point of contact,” Dr Calabrese said.

Delving into the real-world effectiveness of tixagevimab and cilgavimab among patients with immune-mediated inflammatory disease undergoing B-ell depleting therapy and those with inborn errors of humoral immunity, research found that tixagevimab/cilgavimab was well tolerated.

Out of the 412 patients with IMIDs who received pre-exposure prophylaxis between January 2022 and May 2022, 12 patients (2.9%) experienced a breakthrough COVID-19 infection.

In summary, Dr Calabrese said “the virus is not going away.” No one knows what the next phase of this pandemic will look like, he said, but “preventing and effectively treating COVID-19 among the immunocompromised patients is vitally important.”

—Priyam Vora

Reference:

Calabrese L. Challenges of prevention and treatment of COVID-19 in the immunocompromised patient: The next phase of the pandemic. Presented at: Interdisciplinary Autoimmune Summit. April 26-28, 2023. Virtual.