Perhaps no single group saw a bigger increase in attention during the COVID-19 pandemic than the immunocompromised. Immunocompromised patients are defined by relative dysfunction in one or more parts of the immune system. Among the general population, the exact prevalence of compromised immunity is unknown, as it depends on which types of immunity defects are included. What is known is that an immune system may become compromised due to a variety of reasons, including genetics, use of immune-suppressive medication, and vitamin/nutrient deficiency.
The sub-specialty of allergy and immunology has always taken an interest in managing the first cohort: patients with inherited immunity defects, or primary immunodeficiency (PID). In the wake of a COVID-19 pandemic that greatly impacted the immunocompromised, practicing allergist/immunologists examined the future of our approach to patients with PID at the 2022 American College of Allergy, Asthma, and Immunology (ACAAI) Annual Meeting.
In the session “Management of Primary Immunodeficiency Beyond Immunoglobulin Replacement,” moderated by Drs. Shahzad Mustafa and Benjamin Prince, presenters stressed a few key areas to focus on when treating PID patients.
First was the role of antibiotics. All clinicians are trained to be judicious in using antibiotics because most infectious illnesses are viral. However, PID patients are generally much more likely to contract bacterial infections. For these patients, optimal care may warrant treatment with antibiotics despite the risks. In some PIDs, studies of risk and benefit have favored using antibiotics on a prophylactic basis. This may seem anathema to broader trends in medicine, but at least for now, scheduled antibiotics are often the best available tool for treating immunocompromised patients.
The second presentation highlighted the ways in which a vaccine schedule may be tailored to a PID. Prevention of disease through vaccination is a cornerstone of modern healthcare, and even more important when the patient is immunocompromised. PID patients may be recommended to receive certain vaccines (for instance, against pneumonia or shingles) at an earlier age than non-PID patients. Others may be advised to receive additional doses of a given vaccine. Still others may benefit from inoculation against infections that would seem strange or exotic to the average person but pose a danger to patients with PID.
The session’s final presentation covered the use of immunomodulators—agents that suppress certain parts of the immune system — in PID management. Compromised immunity is most frequently associated with vulnerability against infections; however, some of the same defects also lead to higher risk of cancer and poor immune system regulation, with resultant autoimmune disease. At first blush, the use of immunomodulators seems paradoxical: why would you want to use these drugs in someone with an already weak immune system? The success of this approach speaks to the complexity and interconnectedness of the immune system. By restraining an overly active pathway, patients are often able to reallocate resources to insufficient areas of the immune defense.
Much progress has been made toward mapping the immune system in recent decades, with more discoveries certain to come. Despite this progress, the armamentarium for treating immunocompromised patients often feels frustratingly light. Nevertheless, the lively conversation at the 2022 ACAAI Annual Meeting reveals that the needs of such patients are recognized today more than ever before. As novel tools are introduced, these tools will surely be on the menu for discussion at future ACAAI meetings. Allergists and immunologists are poised to remain frontline clinicians in managing patients with inherited compromised immunity, as they continue to strive to protect — and even empower — such patients.
Dr. Kahwash has no conflicts of interest to report.
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