Another concern is “rebound” COVID-19 infections (recurrence of COVID-19 symptoms and/or a new positive viral test after having tested negative).4 “Rebound infections occur in less than 10% of individuals and are probably more common among immunosuppressed patients. Most are mild and transient and don’t require a new round of Paxlovid. But if you have patients on strong immunosuppressants (e.g., rituximab, cyclophosphamide) you might want to consider giving them a second round,” Dr. Jonsson said.
If Paxlovid isn’t an option, remdesivir, monoclonal antibodies and molnupiravir are available. However, Dr. Jonsson kindly warned us that treatment recommendations are always changing, so it’s important to identify and follow local guidance.
Remdesivir is considered second-line for outpatient treatment of COVID-19 in adults and children, but the logistical challenge of three daily outpatient infusions complicates its use. For children younger than 12 years of age, remdesivir is the only option approved by the U.S. Food & Drug Administration (FDA), but there’s “insufficient evidence” to recommend it in this group. Therefore, Dr. Jonsson recommended that we triage our pediatric patients based on overall risk.
“High-risk cases would include patients taking rituximab, mycophenolate mofetil, Janus kinase inhibitors, abatacept, azathioprine or combination immunosuppressants. That’s because these reduce vaccine responses, which is almost the biggest risk factor right now,” she added.
Dr. Jonsson also encouraged us to think about co-morbidities that are risk factors for severe COVID-19 infection (e.g., diabetes and severe asthma) when deciding whether or not to use remdesivir in this age group. These risk factors are listed in a helpful table on the National Institutes of Health website.5
Monoclonal antibodies are third-line options in adults and children aged 12 or older, and only require a single intravenous dose. However, bebtelovimab (the monoclonal antibody currently available) doesn’t work against new variants. New monoclonal antibodies should be available soon.
Molnupiravir should be considered a last resort for dire situations in which there are no other options. It’s contraindicated in patients younger than 18 years of age and should be avoided in both children and adults because it could, in theory, incorporate mutations into human DNA.
“It’s hard to imagine a scenario in which neither Paxlovid nor remdesivir are available options, barring supply issues,” Dr. Jonsson said.
Pre-Exposure Prophylaxis
Tixagevimab/cilgavimab (Evusheld) received Emergency Use Authorization from the FDA for patients with moderate to severe immunosuppression in December 2021 and was a great addition to our prevention armamentarium. Unfortunately, new COVID-19 variants are resistant to it, and it’s unclear how much longer it will remain in use. “We’re hopeful there are some replacements in the pipeline,” Dr. Jonsson said.
