Introduction and Background
CLL Society has been receiving multiple questions surrounding Evusheld and the newly recommended second booster dose (fifth dose in total) for all individuals who are immunocompromised. These new recommendations are applicable to everyone with CLL/SLL.
Dr. S Shahzad Mustafa, MD, Lead Physician – Allergy, Immunology, & Rheumatology and Professor of Medicine at the University of Rochester School of Medicine and Dentistry in Rochester, NY has kindly offered to answer some of the most common questions that we have been receiving.
Please provide guidance on the newly recommended (fifth) dose of COVID-19 vaccines for the immunocompromised.
First, I would like to explain that just because someone has not had a robust COVID-19 antibody response, that does not mean that the vaccine did not stimulate other parts of the immune system that could possibly provide some level of protection as well. The most recent guidance includes that all moderately to severely immunocompromised individuals (which includes everyone with CLL/SLL regardless of treatment status) receive three primary doses and two additional doses. You can read more about the CDC’s recommendations here.
Why should I get Evusheld if I have already received all my vaccinations and had a COVID-19 spike protein antibody response?
Even when patients have measurable antibody responses to the vaccines, those with CLL/SLL are much more likely to have sub-optimal responses to vaccination. In addition, those with CLL/SLL who contract COVID-19 have poorer outcomes and are at higher risk of developing severe disease and even death. Evusheld provides an additional layer of antibody protection that is well tolerated and shown to decrease the risk of infection and development of severe disease with COVID-19.
But if my COVID-19 antibody levels are maxed out, why should I still need it?
We do not yet know how to best interpret COVID-19 antibody levels. Mainly, we do not know what antibody range or level correlates with protection, nor do we know the duration of protection that maxed-out antibody levels may or may not provide for the immunocompromised. For these reasons, Evusheld is recommended as an additional layer of protection specifically for those who are immunocompromised, even when high levels of COVID-19 antibodies are demonstrated.
I’m still in the “Watch and Wait” phase of my disease. So, shouldn’t I wait to receive Evusheld since supplies are limited and let those who are worse off than me get it first?
No. Evusheld has been available since January 2022, with access being better in some areas of the US compared to others. All patients with CLL/SLL are eligible regardless of disease status or treatment status, and Evusheld should be administered right away if available. If you are still having difficulty obtaining a dose of Evusheld, please consider reading here and printing off CLL Society’s Official Statement to take to your healthcare provider.
Does Evusheld really work against the Omicron subvariants because someone told me it doesn’t work as well?
At the time this article was written, Evusheld has proven effectiveness against all previously dominant strains of COVID-19, including the BA.2, BA.2.12, BA.4, and BA.5. Although much like the vaccines, with each successive mutation since BA.2 its efficacy seems to be slowly waning. It is important to remember that Evusheld does not protect against becoming infected with COVID-19. As COVID-19 variants continue to evolve, ongoing research is needed to confirm Evusheld’s activity toward each new variant. So it remains ever important for immunocompromised individuals to wear a well-fitted KN95 or N95 mask whenever they are around other individuals outside of their home.
I heard somewhere that there are cardiac risks associated with getting Evusheld, so how concerned should I be about a heart attack?
Two large studies have shown that Evusheld is effective and well-tolerated with side effects. The risks of cardiac side effects, including heart attack, are quite low and were only found in those who had a previous cardiac history. Therefore, the risks and benefits of obtaining Evusheld to avoid getting COVID-19 far outweigh the risk of cardiac side effects in those with no previous cardiac history for patients with CLL/SLL. But this is a topic that should be discussed with your healthcare provider(s).
I recently received a COVID-19 booster dose, so now how long should I wait before getting Evusheld?
The guidance has been updated to include waiting two weeks after receiving a COVID-19 vaccination dose. You can read more about the CDC guidance here (top of page three).
I’m due for another COVID-19 booster dose, but I already received Evusheld. How long should I wait after getting Evusheld before getting my next COVID-19 booster?
There is no official recommendation to wait any period of time after getting Evusheld to receive another COVID-19 vaccination dose. Although some CLL physicians will still suggest waiting two weeks after receiving Evusheld as well.
How soon after I get Evusheld is it effective/working?
Evusheld should provide increased protection against COVID-19 within days of administration, maybe even quicker. This is because, unlike a vaccination, it does not rely on your body to produce any antibodies. Instead, the antibodies are already produced and injected directly into your system.
Should I still wear a mask and continue taking other precautions such as social distancing after I get Evusheld? Or can I depend on it to protect me completely from COVID-19 infection?
There is no perfect protection against COVID-19. However, there are now many tools that we have available to us as part of the toolkit. These tools include the combination of vaccination, Evusheld, and additional risk mitigation strategies such as always wearing a well-fitted N95 or KN95 face mask when you are around others who are not part of your household. Also consistently remember to use good hand hygiene, social distancing, avoid indoor settings when possible, and avoid large crowds as additional tools. Please refer to the COVID-19 Action Plan for more information. The more tools we have in place, the better.
How often should I expect to need to get additional doses of Evusheld in the future?
We know that Evusheld antibodies are still detectable after six months. The most recent update came out on June 29, 2022. You can read more about the updated FDA dosing guidance here.
According to the newest FDA dosing guidance, patients who have already received Evusheld should receive an additional full dose of Evusheld (300 mg of tixagevimab and 300 mg of cilgavimab) every 6 months. Repeat dosing should be timed from the date of the last dose.
It is important to keep in mind that future updated recommendations surrounding the timing of additional doses will be dependent upon many factors, mainly what the circulating variant is at the time and how well Evusheld continues to work against it. Please stay tuned to the website (or sign up for CLL Society’s weekly Newsletter) as we will be communicating any future FDA updates regarding Evusheld as soon as we hear of them.
My healthcare provider said as someone with CLL, I don’t qualify for Evusheld yet? Is that true? If they won’t write a prescription for it, then how do I get it if I still want it?
Evusheld is indicated for all individuals who are moderately to severely immunocompromised, which includes all patients with CLL regardless of treatment status. The availability of doses is largely based on where in the US you are located. Many of the larger academic institutions have set parameters or a “tiering system” that may or may not prioritize those with CLL/SLL to receive doses yet. However, we encourage everyone to keep advocating and searching. Many have reported being able to obtain doses in locations other than their treating cancer center in locations that are more rural or where their primary care provider practices.
As Sotrovimab is no longer the COVID-19 monoclonal antibody (CmAb) to receive if you get COVID now due to the Omicron subvariants, should people specifically request Bebtelovimab instead if they test positive?
If you test positive for COVID-19, regardless of whether you have previously received Evusheld and/or are up to date on all recommended COVID-19 vaccines for the immunocompromised (which currently includes three primary doses and two booster doses), early treatment for COVID-19 would be recommended given the risk of progression to severe disease for those with CLL/SLL. It is recommended you discuss with your healthcare provider either receiving either an IV infusion of the CmAb called Bebtelovimab, an oral antiviral called Paxlovid, or the IV antiviral Remdesivir.