However, that risk varies by factors like type of rheumatic disease, treatment regimen, age and comorbidities. Compared with the general population, rheumatology patients are likely at higher risk for acquiring COVID-19, Jeffrey Sparks, MD, MMSc, told Healio Rheumatology. “Risk mitigation strategies such as vaccination, masking and social distancing can all lower the risk for acquiring COVID,” he said. Sparks then repeated a refrain voiced by all of the experts who spoke to Healio Rheumatology, in one form or another. “Overall, rheumatology patients likely have slightly higher risk of acquiring COVID than the general population.” “The risk for rheumatology patients acquiring COVID varies by many factors that include type, severity and activity of the underlying condition, immunosuppressive treatment regimen, age and comorbidities, among many others,” he said, noting the broad range of cardiovascular and pulmonary complications seen in these patients. Jeffrey Sparks, MD, MMSc, associate physician at Brigham and Women’s Hospital and Harvard Medical School, dug deeper. “It is not consistent, but it’s there,” she said. She went on to explain how this was like most other data in COVID-19. “Early on, it was not apparent that having an immune-mediated disease increased acquisition risk, but we are starting to see some evidence of elevated infections, particularly in patients with RA and lupus.” While logic might dictate that being immunocompromised would lead to higher risk of acquiring the infection, Calabrese stressed that it is not so simple. Tailoring those individual responses starts with understanding the risk in any given patient. Like with so many of our patients, everything has to be individualized.” “But it is hard to have blanket answers about anything from treatments to booster/additional doses. “COVID is so much of our practice now,” he said. Laster, MD, FACR, a practicing community-based rheumatologist in Charlotte, NC, and president of Arthritis & Osteoporosis Consultants of the Carolinas. If there is a reason for encouragement, it is that rheumatologists are well-versed in managing complicated patient cases, according to Andrew J. But sorting out which drugs are appropriate for which immunocompromised patients and at what point in the infection cycle is a multifaceted equation with no perfect solutions yet. Many experts have hope for monoclonal antibody therapies and antivirals. If vaccines are not working, then effective treatments should be the next priority. What this means for rheumatologists is that, given patient factors and poor vaccine response, the threat of breakthrough infection is considerably higher in immunocompromised individuals than in the general population. Rituximab (Rituxan, Genentech), in particular, has a long history of disruptive impact on any vaccine response, and the same pattern holds true for the COVID-19 shots. Many of the same drugs mentioned by Wallace can also impact vaccine response. “Like with the risks associated with infection itself, vaccine response also depends on the patient’s risk factors,” Cassandra Calabrese, DO, of the department of rheumatologic and immunologic disease at the Cleveland Clinic, said in an interview. These questions open to others regarding the necessity or utility of additional vaccine doses or booster shots. Other clinical challenges faced by immunocompromised individuals surround COVID-19 vaccine efficacy and antibody production. “As in the general population, older patients also do less well.” “Patients with underlying comorbidities, including cardiovascular disease and interstitial lung disease, and poorly controlled rheumatic disease activity may also be at higher risk for poor outcomes,” he said. Wallaceĭisease-related factors are also at play, according to Wallace. “Patients on certain medications, like B-cell depletion, glucocorticoids, JAK inhibitors and others, may be at higher risk for worse outcomes.” Zachary S. Wallace, MD, MSc, of the Clinical Epidemiology Program in the Division of Rheumatology, Allergy, and Immunology at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, told Healio Rheumatology. “Similar to risk for COVID infection, the risk for severe complications is going to vary based on the patient’s demographics and disease-specific features,” Zachary S. One is whether immunocompromised patients are at increased risk for acquiring COVID-19 and another is whether they are at risk for severe complications if they do acquire the virus. There are a number of factors to consider. Marry the two and the challenges more than double. Similarly, nothing is easy in managing immunocompromised patients. Nothing is easy in the management of COVID-19. If you continue to have this issue please contact to Healio