Can a patient with COVID-19 receive their next scheduled injectable immunotherapy injection as planned?

Injectable Immunotherapy During Active COVID-19 Infection

You should withhold the next scheduled injectable immunotherapy injection until the patient meets specific recovery criteria, which typically requires at least 10 days from symptom onset plus clinical improvement. 1

Recommended Approach: Symptoms-Based Strategy

The decision to restart immunotherapy should follow a symptoms-based strategy that requires ALL of the following criteria to be met: 1

• At least 72 hours (3 days) fever-free without the use of fever-reducing medications 1
• Clinically meaningful improvement in respiratory symptoms (e.g., cough, shortness of breath) 1
• At least 10 days have passed since symptoms first appeared 1

Special Considerations Based on COVID-19 Severity

The timing should be influenced by both the severity of COVID-19 and the underlying disease being treated: 1

• Mild COVID-19: May resume therapy after meeting the 10-day minimum criteria 1
• Moderate COVID-19: Consider waiting closer to 10-28 days depending on disease control 1
• Severe COVID-19: May require longer delays before restarting immunotherapy 1

Alternative: Test-Based Strategy

If a more stringent approach is needed (e.g., for high-risk patients or healthcare workers), the above clinical criteria must be met PLUS: 1

• Two consecutive negative nasopharyngeal or oropharyngeal COVID-19 PCR tests collected at least 24 hours apart 1

Asymptomatic COVID-19 Patients

For patients who tested positive but remained completely asymptomatic: 1

• Medication can resume at least 10 days after the first positive test 1
• This assumes they have not subsequently developed symptoms since the positive test 1

Critical Exception: When Disease Activity Demands Treatment

If the underlying condition requiring immunotherapy is severe and poorly controlled, and withholding therapy poses significant risk: 1

• Treatment may proceed despite positive testing if clinical recovery criteria are met 1
• This should be done with appropriate infection control measures in place 1
• Administration can occur at home or in an infusion unit with specific PPE protocols 1

Common Pitfalls to Avoid

• Do not count days from test date if symptoms began earlier - always count the 10-day minimum from symptom onset 1, 2
• Do not restart therapy based solely on negative testing without meeting the clinical criteria of fever resolution and symptom improvement 1
• Do not unnecessarily delay therapy beyond recovery criteria in patients with difficult-to-control underlying disease, as this increases risk of disease flare 1
• Be aware that viral RNA detection can persist long after viable virus is gone - this is why symptoms-based strategy is preferred over test-based for most patients 1

Practical Implementation

For this patient on weekly injections: 1

1. Skip the currently scheduled injection 1
2. Monitor for symptom resolution using the 72-hour fever-free and respiratory improvement criteria 1
3. Resume injections once 10 days have passed from symptom onset AND clinical criteria are met 1
4. Balance the risk of COVID-19 severity against the risk of disease flare from withholding therapy 1

The evidence strongly supports withholding immunosuppressive therapy during active COVID-19 infection to allow for adequate viral clearance and immune recovery, with resumption guided primarily by clinical improvement rather than testing alone. 1