From the Guidelines
Patients with protracted COVID-19 who have received rituximab therapy should have their treatment intervals extended when clinically feasible, and COVID-19 vaccination should be administered prior to rituximab treatment, if possible, due to rituximab's significant impairment of vaccine response, as supported by the study 1. The study 1 highlights the importance of considering the impact of immunosuppressive therapies on vaccine-induced immunity, particularly for patients with rheumatologic and autoimmune disorders. Key considerations for managing protracted COVID-19 in patients on rituximab include:
- Extending the interval between rituximab doses when clinically appropriate, ideally waiting until B-cell recovery begins (typically 6-9 months after the last dose) 1.
- Administering COVID-19 monoclonal antibody prophylaxis, such as tixagevimab/cilgavimab (Evusheld), to provide passive immunity if rituximab treatment cannot be delayed.
- Prioritizing COVID-19 vaccination before initiating rituximab treatment, as rituximab significantly impairs vaccine response, as noted in the study 1.
- Providing supportive care, including rest, adequate hydration, and symptom management, for patients already on rituximab with protracted COVID-19.
- Close monitoring for complications, as these patients may have prolonged viral shedding and delayed viral clearance due to their impaired humoral immunity, as discussed in the study 1. The underlying mechanism involves rituximab's depletion of CD20+ B cells, which compromises antibody production and viral clearance, potentially leading to persistent infection and prolonged symptoms in COVID-19 patients, as explained in the study 1.
From the Research
Protracted Covid Rituximab
- The use of rituximab has been associated with an increased risk of severe COVID-19 outcomes, including hospitalization and mortality 2, 3, 4.
- Studies have shown that patients treated with rituximab may experience a protracted course of COVID-19 pneumonia, potentially due to B cell depletion and impaired humoral response 3, 5.
- The severity of COVID-19 in patients treated with rituximab may be influenced by factors such as age, steroid use, and low CD19 levels 2, 4.
- Some studies suggest that rituximab therapy may be associated with a higher risk of severe COVID-19, including intensive care unit admission and death 2, 4, 5.
- However, there is also evidence to suggest that immunosuppressive drugs like rituximab and corticosteroids may have unexpected positive effects on COVID-19 outcomes in certain patients, potentially by preventing cytokine storms 6.
- The impact of rituximab on COVID-19 outcomes is still being investigated, and more research is needed to fully understand the relationship between rituximab treatment and COVID-19 severity 2, 3, 4, 5.
- Key findings from the studies include:
- A statistically significant association between intensive care unit admission and age, steroid use, and low CD19 levels 2.
- A higher mortality rate in patients treated with rituximab, particularly in elderly, diabetic, and corticosteroid users 2, 4.
- The development of neutralizing anti-spike protein antibodies in over half of the patients treated with rituximab who were checked for antibodies 5.