Antivirals and monoclonal antibodies are life saving, game changing treatments, especially for those of us with blood cancer and hence a disordered immune system. And for those of us who do not make any antibodies in response to vaccines these treatments are even more important. But how do we get ahold of them?

And with omicron rapidly growing in the UK, with its current rate of growth suggesting the whole population may have caught this by sometime in January, this new variant seems much more contagious and therefore is highly likely to spread rapidly worldwide. Even if this causes more mild disease in younger, healthier, vaccinated people, there is a huge risk it is going to continue to cause severe disease in those of us with blood cancer, especially those with particularly weak immune systems.

In the last week a new guidance has been issued by NHS England about treatments that may help us if we do catch COVID, and apparently letters are on their way to us about this. Also the FDA has announced a new EUA for a preventative long-acting monoclonal antibody made by Astra Zeneca. I will try and give a summary here of how you can go about getting treated on both sides of the pond.

It seems important to have a clear plan in mind before you get infected about how you will access these treatments. The CLL society have a helpful checklist which although written for US CLL patients has clear applicability for patients with other types of blood cancer and from different parts of the world.

Back in July I came up with a simple four step plan to save us from getting very sick with COVID. Here it is summarised, and the new information from today’s news is also included.

1. WARN all blood cancer patients that some of us won’t respond at all to vaccines and that we are at high risk of severe illness if we do get infected

Hopefully by now most of us are aware of this. It is true that some of us will have mild disease, but there is a significant risk to all of us whatever stage of our blood cancer that we might have to be hospitalised with severe illness. We want to avoid this.

2. TEST ALL of us for antibodies to see if we have responded to vaccines or or not.

Whilst not a perfect measure, we increasingly see that antibody levels are the best readily available indicator of whether or not our immune system has responded to a vaccine and hence we can feel a bit more comfortable if we have responded, and need to be more cautious if we have not. Low levels of antibodies suggest that additional doses of the vaccine may well boost these up to much higher levels.

The more vaccine doses we have the more likely we are to respond to the vaccine well. By now most of us should have had our third dose, and can apply for our fourth here in the UK. I also know of some blood cancer patients in the USA who have managed to get more vaccine doses than that!

3. Protect us from transmission risks.

Each of us will have different risk tolerances but wearing masks, hand-washing, limiting social contact in indoor settings, ensuring good ventilation can all help reduce the risk of us catching COVID19 in the first place.

With recent advice from the UK government that Omicron is soaring, and blood cancer uk advising us to take extra care some of us will be considering cancelling Christmas gatherings as many NHS employees have been asked to, or withdrawing from all social contact like we did in the days of shielding. This is very hard on us emotionally, and in many cases financially, however. There is hesitancy on behalf of the UK government to impose another lockdown, because the hope is that the vaccine will mean that there are far fewer hospitalisations and deaths this time round. But with the mixed messages, many of us might decide to restrict ourselves. And in case you think this is is just a UK problem, believe me omicron is coming to you, wherever you live in the world.

In a weird way its very speed and the unwillingness to lock down might actually help us in the long term, if we can keep safe until enough people have had it and are then hopefully immune. Perhaps this is the optimum version of coronavirus and further mutations may be less likely to work. The need to target the ACE2 receptor must surely limit how much this virus can mutate. If we can finally get to a position of herd immunity then the rest of the population will shield those of us without immune systems. Provided that is, we are able to avoid catching it before this happens.

Treating blood cancer patients with long acting monoclonal antibodies before we have even been exposed to COVID let alone tested positive really belongs under this heading. Following fantastic results from the Astra Zeneca study that I was a volunteer for the FDA has today announced they have given an emergency authorisation to AstraZeneca’s Evusheld which is a mixture of two monoclonal antibodies given into the muscle and lasting for several months. Here is more detailed medical information about this exciting breakthrough treatment. I hope the UK’s MHRA and other bodies are not far behind in approving this and funding it as quickly as possible. And that there is no delay in funding this. Whilst these cocktails may be less effective against omicron the hope is they will still have an effect.

4. Treat us to reduce the severity of COVID19 infections 

Inpatient treatment

Please remember that there are a number of treatments available as an inpatient. It is worth ensuring you know where a good hospital is for you to be admitted to if you get sick. Ask your blood cancer team for advice on this point and have a plan in mind. The treatments below are outpatient treatments.

Outpatient treatments

For those who prefer video here is a short explanation from a week ago

How to access monoclonal antibodies in the USA if you become positive for COVID19

In the USA it is now possible to get monoclonal antibodies after exposure to COVID19 as soon as you are diagnosed with COVID19 if you have blood cancer and no antibodies to COVID. Contact your Haematologist or Immunologist and ask ahead of time if they can arrange infusions for you and/or contact the national helpline and review their website that explains more. What is less clear is how to access the antibodies for preventative treatment. I would be asking my blood cancer specialist or immunologist this question.

There are a number of treatments including oral or inhaled steroids among others that have been shown to be effective. Talk to your doctor early if you catch COVID19 about what may be appropriate and have a low threshold to get assessed at a hospital to see what treatments you might qualify for. 

How to get monoclonal antibodies in the UK

Until recently the only way to get the antibodies in the UK was to be admitted with COVID19, have an antibody test which showed you were not making antibodies and then if negative have the infusion. Clearly this is not the best way to prevent severe disease.

So NHS England has issued a new process for us to access this life saving treatment in the first few days of a COVID infection.

Who is eligible in the UK?

Whilst this list is UK specific it may help you as you think about whether you should try and get this treatment elsewhere in the world, it also reflects those people with blood cancer believed to be at the greatest risk from COVID19 due to their level of immune compromise. This list has been reworded for clarity form the NHS list.

• Stem cell transplant (HSCT) recipients from the last 12 months or with active graft vs host disease (GVHD) regardless of time from transplant
• Anyone treated with (CAR)-T cell therapy in the last 24 months
• Anyone treated with an anti-CD20 monoclonal antibody (e.g. rituximab or obinituzimab) in the last 12 months
• Anyone with a chronic B-cell blood cancer (eg CLL, SLL, NHL, etc) at any stage, especially if
  • You have had any chemotherapy, selective drugs, or radiotherapy within the last three months
  • You have a low blood lymphocyte count or have low antibody levels
• Individuals with acute leukaemias and clinically aggressive lymphomas who are receiving chemotherapy or within last 3 months.
• Individuals with blood cancer who have received anti-CD38 monoclonal antibody or B- cell maturation agent (BCMA) targeted therapy in the last 6 months

Some people with blood cancer who are NOT on this list are also getting the letter and if I was one of them I would still take the treatment if it is on offer. I suppose this is a prioritised list of who they think are at the very highest risk.

Several of the antibody cocktails have been shown NOT to work against omicron but there are two which have. As well as the long-acting one mentioned above, Evusheld, a GSK short-acting one called Sotrovimab has been shown to work in lab tests, so this is the cocktail the NHS are offering via home infusion in the community.

If you have received a letter, great. But I wouldn’t wait to be called if I got a positive PCR test. Ring your hospital, GP, or 111 as soon as you get that result as speed is of the essence here.

We are advised to hold a PCR test at home and send it off if we get sick. An alternative which might sometimes be faster is to book a drive-through PCR test where the results are often available the following day.

Your GP, 111, or your hospital should all be able to refer you to the community treatment if you get a positive PCR COVID test.

** Blood Cancer UK have an excellent page summarising monoclonal antibodies.

** The NHS has a page summarising both outpatient treatments for COVID now available.

How to get the antiviral in the UK

I am disappointed to report that at the moment it seems people are going to be offered either the antibody or the antiviral in the UK. That is what NHS England suggests in their statement and the suggestion is that if eligible the antibody is to be preferred as it has better efficacy. I find this disappointing and lacking in imagination as ideally I would want to take BOTH treatments.

Fortunately, there is however also a study that blood cancer UK reports we should be eligible for, which we can enrol in even if we are given the antibody. It is randomised so you only have a 50/50 chance of getting the active treatment but I know that volunteering for this trial would definitely be part of my COVID plan.

Volunteer for the Oxford remote trial of antivirals for mild COVID19

So far I believe it is not yet possible to get the outpatient antivirals in the USA yet. Hopefully that will change soon.

The situation is rapidly changing. In the UK the Blood Cancer UK website is a good one to keep an eye on.