Despite some confounding research findings, Dr. Kim notes it was an exciting time to see immunity in action. “We are seeing in real time how this impacts not only autoimmunity, but also infectious threats and vaccine responses,” he says.
Understanding When to Use Therapies
Dr. Hausmann and Dr. Kim also note some of the contradictions surrounding rheumatic disease and COVID-19 therapy: Prednisone use may increase the risk of poor outcomes in COVID-19, but dexamethasone emerged as one of the first COVID-19 treatments. Anti-inflammatory drugs and cytokine inhibitors were in the mix to treat severe COVID-19.
“This was confusing when it came out, but I think right now what’s pretty clear is that with early COVID-19 infection, you need a robust immune response to try to control viral load, eliminate the virus and generate adequate immune responses,” Dr. Kim says. After the virus becomes severe, the immune response is pathogenic. “That is obviously the driving impetus of why immunosuppression is both a threat earlier, but also can be used as a treatment later on.”
This paradox was problematic to describe to regular people. “It was not something that was well elucidated or described by us as a profession. It led to a lot of confusion,” Dr. Kim says.
Expanded knowledge about COVID-19 led Dr. Kim to prescribe B cell-depleting therapy less frequently. This change led to some skepticism from certain patient groups, such as patients with lupus on rituximab who may have taken a long time to find the medication mix that put their disease in remission.
“I was a little surprised initially, but it makes a lot of sense when you think of it from their perspective and why they want to continue it,” he says.
Vaccination & B Cell-Depleting Therapies
Research revealed that patients on B cell-depleting therapy had a reduced response to COVID-19 vaccination, leading to concern.
“On Twitter, it became massive threads of people trying to figure out, ‘How do I mitigate this?’ or trying to take things into their own hands, which may have led to some people making decisions that we wouldn’t have necessarily advocated,” Dr. Kim says. “This includes trying to boost their immune system using whatever supplement they could find on the internet.”
The ACR recommended vaccines for every patient with rheumatic disease, including those on B cell-depleting therapies. Additional vaccine doses were recommended for some patients on B cell-depleting therapies and other immunosuppressive drugs.3
