An Overview of Immunosuppression in COVID-19 Patients

PracticeUpdate: How do you approach immunosuppression in patients who are COVID-19 positive?

Dr. Casteel: This is a very tough call and ASH does in their recommendations address this and they actually had recommended considering holding off on immunosuppression, or even chemotherapy, for a patient with a serious hematologic illness such as acute leukemia, if possible, if the patient tests positive for SARS-CoV-2, even if they are an asymptomatic carrier, so not showing signs of COVID disease, but they have a positive test. And this is an area where I'm not aware of data that can help us one way or the other. And I've seen both things happen here in our clinical practice at MD Anderson ASH does recommend, and I think most hospitals have guidelines reflecting this, that if somebody is going to be admitted for chemotherapy, like other procedures, including surgeries, we're now testing these patients at the time of admission or shortly before admission, depending on the turnaround time locally of the test results.

And so what to do if somebody is admitted with a hematologic cancer that really needs treatment fairly urgently and they're incidentally found to be positive for SARS-CoV-2? ASH suggests that you should hold off on treating them if possible, and I think that's consistent with what we have done here. But in some cases, we've felt that the risk of delaying treatment of the blood cancer really forces us to begin treatment in a patient who is asymptomatic.

PracticeUpdate: What about patients who have both an aggressive malignancy and severe COVID-19?

Dr. Casteel: If somebody is hospitalized with severe COVID illness and they have a concurrent, aggressive hematologic malignancy, this is a very difficult situation and has to be individualized based on all the factors going on with the patient. So I know that some of our leukemia folks have used temporizing cytoreductive agents in some of these patients, just as we would with any infection, to allow them to get through that critical infectious period before we can put them through a more rigorous, cancer-directed regimen.

PracticeUpdate: Is there a specific guidepost that you use - so many days after a PCR test is negative, for example - when you might resume the immunosuppressive therapy?

Dr. Casteel: That's a great question. I'm not aware that we have standardized ones. And other things we have to consider are, what is the CDC guideline on how contagious that patient is? Because part of the limitation is having somebody to administer the therapy, whatever it may be. So I don't know, off the top of my head, our specific institutional guidelines, but of course we're trying to limit patients' exposure to nursing staff, phlebotomy staff, and being moved around the hospital for whatever imaging might be required before starting that therapy as well. So I expect that our number of day cutoff after a positive test has changed over time with the CDC guidelines based on how long that patient needs to be quarantined. From a perspective like the medical management of this specific patient, I'm not aware of a specific guideline. I think it's individualized based on that patient's presence or absence of symptoms and their overall clinical picture when we've had to delay.