Should I Continue With COVID Vaccines Even When Not Producing Antibodies?

Experts responded to listener questions during our January 13, 2023 virtual town hall. Watch the full webinar here.

Jeff:    

Susan has this to tee up: My husband has responded well to treatment and has received all the COVID vaccines and boosters. An initial antigen test result taken just two weeks after his bivalent booster in late September was 327. The second antigen test, taken six weeks later, showed no antigens. Is it even necessary for him to receive them if his body is producing little to no antigens? Dr. Jain?

Dr. Jain:          

Well, you know, I think this is a tough situation. And I think it’s where we don’t have much medical – I mean we have some medical data in the context of CLL patients, but we know from the very beginning – this has now been going on for three years – the pandemic, that patients with CLL, especially patients who are on treatment such as ibrutinib (Imbruvica) or CD20 antibody, or for that matter venetoclax (Venclexta) as well, that they do not respond well to immunization, the COVID vaccination. It’s not that it’s zero, like no one responds. The rates of response were from 20 to 30 percent in patients with ibrutinib.

 So, I think a recommendation at least at my clinic, especially when the vaccinations came about over the last years, is for you to be fully vaccinated, because you may get some benefit out of it, and we do not know who may or may not respond to the vaccination. So, I think, but you’re absolutely right, as the person who asked the question, certainly there are patients who do not respond to vaccination despite multiple doses of boosters.

 Previously up until recently we had tixagevimab/cilgavimab (Evusheld), which is now off the market, but it was available, and I don’t know if something similar to Evusheld, which is the antibody’s itself, what has been planned for the new strains of the virus going around. But up until a few weeks ago or a few months ago, we were slowly asking patients to take Evusheld. As I said, that is off the market right now, because the new strain of the virus is not covered by the Evusheld antibodies.

 Jeff:    

So, along those lines, Dr. Wierda, what is the best way to treat COVID, flu, and even the common cold at onset? Craig is dying to know.

Dr. Wierda:    

So, I’ll just make a couple other additional comments about the vaccine.

Jeff:    

Sure.

Dr. Wierda:    

We heard about quantitative test for antibodies, I believe. You said antigen, but it was probably antibodies, and the person who was asking the question was probably meaning to say antibody levels that were tested for and identified. Remember, the immune system has two main arms: the humoral arm or the antibody arm, and the cell arm. And the cell arm – and they are interrelated but they are separate, so you do get responses, although we don’t measure those, in terms of cellular immunity, and that can be helpful and important in clearing viral infections – very important, in fact.

 We don’t talk a lot about cell responses, and what’s the meaning of that. I do think that you get benefit from a vaccine even if you’re not seeing an antibody response. So, I would not discourage any patient from getting a booster, particularly one of the newer boosters with the bivalent strains – or the bivalent vaccine. I think the other thing to emphasize is that now we have some antiviral agents that we didn’t have before. One is called nirmatrelvir/ritonavir (Paxlovid), the other is called remdesivir (Veklury).

Paxlovid is an oral drug, it can be administered as an outpatient. It’s indicated for patients who are not sick enough to be in the hospital but are at risk for developing more severe symptoms. Remdesivir is usually reserved for more severe patients, hospitalized – treatment for patients who are hospitalized for their COVID. But the point is that we do have antivirals that we can use that are more effective if they’re used earlier in an infection.

You can get a home antigen test now that you can take at your leisure at your home that’s distributed by our pharmacies, so I would encourage everyone to have one of those tests on hand. If they develop symptoms, get tested. If they test positive for the antigen, call your doctor and tell them you test positive and that you may need an antiviral. It’s a five-day course of a drug, and that has been effective at reducing the severity of symptoms and reducing the requirement for hospitalization, particularly for Paxlovid. Patients can have a recurrence of their or a flare of their infection after they finish their course of Paxlovid.

 Some patients, and even people who don’t have a hematologic malignancy, have required a second course of Paxlovid. I think the one thing with COVID you can count on is things will be changing, and what we do today is different than probably what we’re going to be doing in six months. So stay alert and stay informed about it.