Editor’s note: The U.S. Food & Drug Administration’s emergency use authorizations are subject to change as circumstances evolve. Check current information on the FDA’s website.
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When oral antiviral drugs for COVID-19 are available, use them early and as aggressively as possible, said Michael S. Saag, MD, professor of medicine at University of Alabama–Birmingham, at a virtual ACR town hall on Jan. 19, 2022. The immune system needs as much help as possible to get the SARS-CoV-2 virus under control in patients on immunosuppressive drugs, he added.
During the town hall, an expert panel discussed risk factors for poor COVID-19 outcomes, as well as the use of oral antiviral therapy for rheumatology patients with COVID-19. They also talked about monoclonal antibody therapy and the best use of vaccines. The panel included Dr. Saag, Monica Gandhi, MD, MPH, professor of medicine and associate chief of the division of HIV, infectious diseases and global medicine at the University of California, San Francisco, and Andrew T. Pavia, MD, adjunct professor of internal medicine, professor of pediatrics and chief of the division of pediatric infectious diseases at the University of Utah, Salt Lake City.
Timing Is Key
When considering which rheumatology patients are prone to poor COVID-19 outcomes, Dr. Saag suggested the natural course of COVID-19 should be considered. He explained that the initial four to seven days after SARS-CoV-2 infection is the viremic phase, when most patients exhibit symptoms and the innate immune response is triggered. The second phase, from days six to 14, is when the adaptive immune response is activated.
Rheumatic patients on immunosuppression have an inhibited adaptive response, setting them up for a prolonged viremic phase. “If glucocorticoids are prescribed in the first phase, viral replication is prolonged,” Dr. Saag said, calling this “a common mistake” that may lead to longer illness.
Emerging data—mainly observational—suggest that immunosuppressive drugs confer different risks for poor COVID-19 outcomes and vaccine responses in immunocompromised patients, Dr. Pavia said. B cell-modifying drugs are associated with the highest risk, and tumor necrosis factor inhibitors appear to have the least impact on COVID-19 outcomes. Hydrocortisone, Janus kinase (JAK) inhibitors and mycophenolate fall in between, and azathioprine has shown conflicting results.
Other patient factors also matter, especially age. “For the same amount of immunosuppression, someone who is 75 is at a much higher risk than someone who is 35,” Dr. Pavia said.