Inhibition of Bruton tyrosine kinase in patients with severe COVID-19
The COVID-19 (Coronavirus 19) is potentially very dangerous to CLL patients. Most CLL patients already fall into the higher risk group because of their age. Additionally, all CLL patients have compromised immune systems that are less likely to be able to fight early infection with their innate immune system and also clear the virus with long-lasting immunity from their adaptive immune system. Additionally, this is an entirely new virus that their immune system did not see prior to developing the impairment from CLL so we are not protected by our “older” antibodies as we are against many childhood illnesses.
Special precautions have to be taken that some may consider draconian. The best strategy in my opinion is for patients is to be proactive and take control and take action to do things that could prevent exposure to this. While most people likely will eventually be exposed to this, a latter time will ensure more is known both about the infection and how people should be treated. As we have talked in the past concerning therapy for CLL itself, delaying exposure could mean there will be something better known for prevention and treatment of COVID-19. It is also possible that we will find out the risk to CLL patients is less in the upcoming months. However, until that time, I would recommend the following:
- Avoid anyone with direct exposure to an infected COVID-19 person or symptoms of this virus, at this time, it is not clear how long patients with COVID-19 remain infectious.
- Avoid anyone returning from personal airline travel, regardless of location, or returning from a high-risk area, regardless of mode of transportation, for at least 14 days.
- Frequent handwashing is crucial. Avoid door knobs and handles in public places or use a tissue to limit contact with surfaces. Do not touch your face, eyes, mouth, or ears. Avoid handshaking; rather practice foot tap or elbow bumps as a way of greeting others, if needed.
- If you work in a high risk job such as teaching/supervising/interacting with children, service work where you are exposed to many individuals, direct health care providers (including physicians), consider taking a leave of absence or using your sick leave (after advice from your personal physician). I am giving people with these high-risk activities notes to allow isolated work at home, off site, or in a place away from others. If this is not possible, ask your employer if it is possible for you to have work isolated from these high exposure risks such as doing desk work.
- Clean shared work surfaces at work after each use. This includes wiping down the keyboard, computer mouse and phone. If you see someone not doing this, please remind them of it. This is a very good practice at all times, but especially now.
- All face-to-face group meetings of more than 4 people should be canceled. Video conferencing as an alternative that should be considered.
- Practice social distancing as the best way to limit the spread of disease, especially around anyone who appears ill or has a cough. Apply this principle at work, home, and in your social network. It is a good idea to avoid large group events during the time of this pandemic including sports events, church, club meetings, weddings, family reunions, etc. Your churches and clubs still need your support so continue tithing, but do this online.
- Encourage people not to come to work or to activities when sick! Notify your healthcare provider or PCP if you have the symptoms of coronavirus COVID-19 (cough, muscle aches, shortness of breath and fever greater than 100.4º). Muscle aches alone are okay if you have exercised robustly the day before. If in doubt about your symptoms or starting to get sick, please stay at home.
- If you develop influenza or COVID-19 and have low immunoglobulins, I will be recommending that you receive IVIG therapy to replace this. Application of IVIG in this setting can potentially help protect you from developing bacterial pneumonia as a complication following a viral infection. It will likely not help the COVID-19 itself.
- Know how you can help others with our good advice. We are all thinking of our friends and loved ones at this time as well. The recommendations above are what I am telling others who ask me. If you have parents, grandparents or friends that are older than 70, my personal advice would be to not visit them during the next two to four weeks and encourage them to stay at home. They should avoid contact with younger people (including children). Children and young adults can have this without being sick and pass it on to elderly patients at risk. This is the biggest risk population for being harmed by the COVID-19 virus infection.
- If you have early-stage CLL, are not being treated, and have had stable blood counts,or if your disease is very stable, regardless of your treatment status, it may be better to discuss with your doctor about postponing your routine follow up visits to your doctor for at least 1-3 months while the initial wave of COVID-19 infections are being dealt with. Hospitals or doctor’s offices are much more likely to have sick patients who could have this. We are following up with patients by phone in this setting to determine any new symptoms and when necessary having them get their counts checked.
- Patients on active treatment should still be seen as scheduled by their physician and health care team. We do not know how COVID-19 will affect CLL patients on therapy but hope that at least with the targeted therapies such as ibrutinib, acalabrutinib, idelalisib and duvelisib which improve immune function of CLL patients, that the risk of more serious infection will not be affected. With other agents used in CLL I am less certain.
Check the CDC website regularly for the most accurate and up-to-date information: About COVID-19 or here for high risk populations.
We are at a special time that requires all of us to work together and support one another. These suggestions are ones I am providing my own patients as of today. As more data emerge it is likely these will change.
John C. Byrd M.D.
Distinguished University Professor
D. Warren Brown Chair of Leukemia Research
Senior Adviser for Cancer Experimental Therapeutics and Co-Director Leukemia Program
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
Columbus, Ohio 43210
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