By James T. Rosenbaum, MD
6/21/2022
Vaccination remains the first line of defense against COVID-19 for those who live with spondyloarthritis (SpA). In an earlier article, I discussed the most recent guidelines and CDC recommendations for those who are immunocompromised or taking immunosuppressive medications.1 But beyond vaccination, there are several new medical approaches to prevent or treat COVID-19.
Some of these newer alternatives involve monoclonal antibodies. A monoclonal antibody is a medication that is engineered in a laboratory to find a very specific target. Many patients with SpA are familiar with monoclonal antibodies that target proteins in the body such as TNF or IL-17. Similarly, we now have monoclonal antibodies that can target the coronavirus and help to neutralize it.
A Strategy for Prevention
One combination of monoclonal antibodies that has been studied to prevent COVID-19 is called Evusheld. Evusheld is an injection that is effective as a preventative measure for individuals aged 12 years or older, who are moderately to severely immunocompromised, or who are not able to complete their vaccinations due to a history of adverse reactions.2,3 The protective benefit from this injection lasts about six months. Evusheld is in limited supply. The availability of Evusheld is usually determined by a priority list that categorizes patients into tiers based on their age (elderly patients have priority), their vaccination status (patients unable to complete their vaccines have priority, but this medication should not be viewed as a substitute for vaccination), their degree of immunosuppression, and their additional COVID-19 risk factors. The use of Evusheld is sometimes called PrEP for “pre-exposure prophylaxis.” Evusheld reduces the risk of a symptomatic infection by about 77 percent. Patients who are receiving TNF inhibitors do qualify, but their priority status is low—particularly if receiving TNF inhibitors is the sole qualifying factor.. It is generally well-tolerated but rare, severe heart-related events have occurred.
Strategies for Those with Mild to Moderate COVID-19
If you have tested positive for COVID-19, you should talk to your health care provider, who might recommend one of the available treatment options: a pill called Paxlovid, a monoclonal antibody called Beptelovimab, which is given by injection, or an antiviral drug called Remdesivir, given intravenously.
The pill (Paxlovid) directly interferes with the virus’ ability to replicate in your body. It must be started within five days of the onset of symptoms, and it is taken for five consecutive days. You must be 12 years or older; there should be no severe kidney or liver disease; and it will interfere with the effectiveness of hormone-based birth control. It can also interact with a variety of medications. This pill is very effective and seems to be superior to an alternative called molnupiravir. However, by reducing the viral load, taking Paxlovid could affect your body’s ability to make its own antibodies. Because of this, some patients feel well while on Paxlovid but can develop rebound symptoms once the medication is stopped. The rebound illness is usually mild, but it still prolongs the quarantine phase.
Beptelovimab is a monoclonal antibody, which is an alternative to Paxlovid. It is given by injection into the muscle within seven days of the onset of symptoms. It is generally effective and well-tolerated.
Remdesivir is an antiviral drug originally developed to treat hepatitis C. It can be given intravenously in the hospital to treat COVID-19 or it could be administered daily for three days by home infusion.
As noted above, none of these treatments is meant to replace vaccination. Also, none of these treatments is meant for those who are severely ill, although Remdesivir can be given during hospitalization or if a low level of oxygen is needed for treatment. Due to cost, inconvenience, and the slight risks they carry, many patients with COVID-19 do not opt for any of these approaches if their symptoms are mild and if their risk profile is relatively low.
Thanks to YoungYoon Ham, Pharm. D., for providing a critical review of this article.
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