14. How to Compromise with Immunocompromised Patients about COVID-19

00;01;33;22 – 00;02;02;02

Dr. Christopher Smyre

Hi. Welcome to IVAC’s podcast series. Thank you for joining us on today’s episode on How to Compromise with the Immunocompromised. My name is Dr. Christopher Smyre. I’m a family medicine physician at SIU School of Medicine in Springfield, Illinois, and I’ve been in practice for now three years as a full-fledged attending. I’m joined by two other great doctors, Dr. Timothy Ott and Dr. Carl Lambert.

00;02;02;03 – 00;02;07;02

Dr. Christopher Smyre

I’ll let Dr. Timothy Ott introduce and give his background and then Dr. Lambert will give his background.

00;02;08;19 – 00;02;40;07

Dr. Timothy Ott

Good morning, and thank you again for joining us today. My name is Dr. Timothy Ott. I’ve been practicing family medicine for over 35 years now. I’m currently an academic family doc with S.I.U. Quincy Family Medicine Residency and enjoy working with patients from all backgrounds and the care of people who are immunocompromised. Which is near and dear to my heart.

00;02;42;10 – 00;02;44;01

Dr. Timothy Ott

Carl, do you want to introduce yourself?

00;02;44;16 – 00;03;06;03

Dr. Carl Lambert, Jr.

Yeah, absolutely. Greetings to everyone who is listening. My name is Carl Lambert. I’m a family physician. I’ve been practicing for about ten years, and I’m an assistant professor of family medicine at Rush Medical College in Chicago, Illinois. I see patients of a variety of backgrounds and also, as we’ll probably discuss later immunocompromise is lately been something that’s been near and dear to my heart as well.

00;03;06;17 – 00;03;26;24

Dr. Christopher Smyre

Thanks for that introduction Carl. So the reality is no one is immune to COVID affecting their lives in some sort of way. And when we think about the immunocompromised, we want to talk today and cover sort of how personal challenges can be for people who have loved ones and friends who are dealing with various illnesses that compromise their immune system.

00;03;27;05 – 00;03;49;13

Dr. Christopher Smyre

We’re also going to talk about some various treatment options for those that have moderate, severe or immunocompromised states, as well as talking about sort of the experience and challenges of a patient with the things that they’re having to weigh and think through. And so as alluded by all three of us, is that we all have loved ones who have immunocompromised state. And just being transparent, my mother actually has sarcoidosis and so when she was talking and thinking about getting the vaccine, there’s a lot of conversations that I had with her, some discussing her own concerns and fears of if I  get this will my immune system be activated to make the antibodies. But, if it get over activated, what is that going to mean for me?

00;04;08;29 – 00;04;33;01

Dr. Christopher Smyre

Or is it even going to work because I’m on these other medicines to keep my immune system in check. And so having conversations with her about the pros and cons, having her to talk with her own primary care doctor, about those pros and cons to decide when would it be right to get the vaccine? And weighing the risks and benefits of how to keep her as healthy as possible was something that was a straightforward answer, especially when the vaccine came out.

00;04;33;17 – 00;04;54;21

Dr. Christopher Smyre

Thankfully, we have more information now so that there’s a little bit better understanding and guidance for people who are immunocompromised.  But this is something that requires a lot of conversation and nuance to make sure that people understand sort of how to walk that fine line that often people are having to do. Tim, would you like to share your own personal relationship with people who have immunocompromised states?

00;04;55;10 – 00;05;30;03

Dr. Timothy Ott

Yes, thank you, Dr. Smyre. My daughter, who’s 32 years old, has an inflammatory arthritis that affects her a lot. So she’s on methotrexate to suppress her arthritis. And methotrexate is immunosuppressant an old chemotherapy drugs. And initially she didn’t think she could get the vaccine. And so in talking with her I encouraged her to talk to her providers about it and talk to her about my knowledge of the vaccine and immunocompromised.

00;05;30;04 – 00;05;44;18

Dr. Timothy Ott

And I was able to convince her and she was able to convince her doctors that she should get the COVID vaccine. So I think that was a little personal victory for me and her. Dr. Lambert, you have a personal story, too?

00;05;45;03 – 00;06;04;21

Dr. Carl Lambert, Jr.

Oh, absolutely, I do. So it’s very interesting how at the time of this recording, there was a lot of talk about the CDC now recommending a vaccine for those, you know, six months to five years old. So I’m a new parent. I got a almost 11 month old son at home down the hall. He was born very early.

00;06;04;21 – 00;06;31;14

Dr. Carl Lambert, Jr.

He was born at 27 weeks and had a really prolonged hospital stay of nine months in the ICU. Ultimately, he was diagnosed with severe BPD, bronchial pulmonary dysplasia and requiring even a tracheostomy to help him to breathe. Now, thankfully, he’s doing well overall, but just that combination of prematurity and then also just chronic lung disease most certainly would make him immunocompromised and at risk for COVID-19.

00;06;31;14 – 00;06;49;04

Dr. Carl Lambert, Jr.

So it’s certainly, and I think this is even a discussion I would have with patients who aren’t kids, But when you discuss COVID-19 vaccine and whether or not you should get it, sometimes I’ll say getting the vaccine may be the difference between you recuperating at home versus having to be in the ICU for a week or so to recover.

00;06;49;04 – 00;06;58;02

Dr. Carl Lambert, Jr.

So there’s a lot of discussion of like pros versus cons, and you discuss going for this in patients who are immunocompromised. So that’s my personal story. To share.

00;06;58;14 – 00;07;11;26

Dr. Christopher Smyre

Thank you for sharing both of you. And we’ve been throwing around the word immunocompromised a lot here. But just so we’re all on the same page, can you give us a definition for those who may wonder what all constitutes someone being immunocompromised?

00;07;12;06 – 00;07;36;03

Dr. Carl Lambert, Jr.

Yeah, absolutely. So I’m preaching to the choir here, but there’s a myriad of things that we can do to kind of help prevent infection that could be avoiding large gatherings, social distancing, wearing our masks, early testing and whatnot. But really, the baseline of protection is really our immune system. So there are cells in our body that work in concert with one another to really fight off infections and pathogens of different kinds.

00;07;36;13 – 00;07;55;23

Dr. Carl Lambert, Jr.

Now, there is such a thing as being immunocompromised. So that means that there are people or patients that we serve that may have weakened or again compromised immune systems that don’t work fully, don’t have that robust response that we’re looking for when they come across a bacteria or a virus or whatever the agent is. So that could be inherited.

00;07;55;27 – 00;08;14;29

Dr. Carl Lambert, Jr.

You could be born with immunocompromised or could even be caused by medications or certain treatment plans and whatnot. So when you discuss this with patients, sometimes patients will say, hey, am I immunocompromised? Or not? So we do have to keep the main thing, the main thing as far as definitions are concerned. So you know who’s considered moderately or severely immunocompromised?

00;08;14;29 – 00;08;33;29

Dr. Carl Lambert, Jr.

It was there’s a list of common things that I think about. So if it’s a patient who’s going through active chemotherapy or radiation for tumors or blood cancers, that’s certainly immunocompromised. If you had an organ transplant or if you’re taking medicines, that helps to prevent your body from rejecting the transplant. But again, that’s certainly a state of immunocompromised.

00;08;34;07 – 00;08;59;01

Dr. Carl Lambert, Jr.

If you have a condition such as HIV or AIDS that’s untreated or advanced, that’s another category for immunocompromised. If you’re taking certain medicines that again, cause your immune system to kind of stay calm or not to overreact like steroids or like prednisone or things of that nature, if you’re taking more than 20 milligrams daily or other medicines like methotrexate, which is used for some arthritis conditions, that’s another state of immunocompromised.

00;08;59;09 – 00;09;15;00

Dr. Carl Lambert, Jr.

And then finally, if you have what we call a primary immunodeficiency, which you’re born with, such as the DiGeorge Syndrome, or Wiskott-Aldrich Syndrome.  Those are conditions that you’re born with it at birth. So again, those are kind of the main contenders in terms of thinking about immunocompromised.

00;09;15;13 – 00;09;35;00

Dr. Christopher Smyre

Thanks for that working definition. And with anything, there’s always are levels of this or severity of illness. And so depending on how severe it is, we’ll determine what options may be available. And an option that many people may not know about is something called Evusheld. So Tim, can you tell us a little bit more about Evusheld.

00;09;35;16 – 00;10;19;15

Dr. Timothy Ott

Yeah, I’d be happy to talk about Evusheld a little bit, but what Doctor Lambert defined was the moderate to severe immunocompromised. And there is a category for mild immunocompromise, which there’s a little different immunization recommendations for mild immunocompromised, and that includes anybody over 65, anybody with type two diabetes. A lot of those things where they’re recommending the, the booster vaccine, those are considered mild immunocompromised just to sort of differentiate between the moderate to severe and the mild immunocompromise.  When it comes to Evusheld we’re talking again about those moderate to severe immunocompromised patients that Dr. Lambert defined very well.

00;10;19;22 – 00;10;53;03

Dr. Timothy Ott

What the Evusheld is, is a pre-exposure prophylaxis. It’s two shots composed of two different monoclonal antibodies. And it’s mostly for people that can’t get the vaccine or didn’t respond to the vaccine, and it’s to give them external monoclonal antibodies against so that when they can’t produce their own monoclonal antibodies, against COVID, it’s approved for 12 and over who are moderately to severe immune compromised due to those diseases.

00;10;53;03 – 00;11;25;22

Dr. Timothy Ott

Their meds and are currently not exposed and who have not been recently exposed. So it’s a pre-exposure prophylaxis. It’s also approved for anybody who had a severe allergic reaction to the COVID vaccine, which initially was a concern. But we found with more and more vaccines that that’s actually very rare. So, it’s just important to know that the Evusheld out there, it is approved under the Emergency Authorization Act and available free of charge.  And it’s just these two shots of monoclonal antibodies for pre-exposure prophylaxis if you’re concerned your high risk patient might be exposed.

00;11;37;12 – 00;12;06;10

Dr. Christopher Smyre

Thanks for talking about that and sharing more about some of the newer options or some things that we can do to keep people from getting COVID, especially if the vaccine didn’t respond. Well, it or there’s a contraindication to giving that. One of the realities, especially for people who are immunocompromised, or having to think through a little bit more nuance of sort of what makes the most sense for them, is that it then leads to very interesting conversations that we’re having to have with our patients to help elaborate on the risks and benefits for them.

00;12;06;25 – 00;12;44;20

Dr. Christopher Smyre

And I know that those conversations can be sometimes challenging. Sometimes you may feel like you don’t know enough about how to best manage or counsel patients. So we’re going to share a little bit about how we have navigated sort of educating and discussing with our patients who are being compromised I know for me, one of the things that often came up was sort of I worry my body isn’t flexing like the typical body does, so how is this vaccine going to respond in my body, which is different than most people’s bodies. Especially if they have diseases, they can overreact when activate it and many of them were so afraid of having another flare up or doing anything that would cause a flare up, they would have hesitancy to getting the vaccine was activate the immune system. And so one of the things that I found helpful was validating those concerns, helping to explain and make sure that they really did understand how the vaccine worked, risks and benefits. And then sort of reassuring them now that we have more people who have gotten vaccinated with various diseases.

00;13;07;01 – 00;13;41;26

Dr. Christopher Smyre

But before that, I would say those are legitimate questions. Why don’t we talk with a specialist who may be more focused in that area to sort of see what their thoughts are and see they’re also in agreement. We’re getting the vaccine. And what I found for a lot of my patients was letting them talk to a specialist or someone that’s a little bit more focused in that particular area of disease gave a lot of reassurance with what we would be looking for, how we respond if something happened unexpectedly, and then that was enough to sort of move them forward with getting the vaccine, as well as having to understand that because of their immunocompromised state, they were actually a higher priority and not someone that should avoid the vaccine altogether. But that was my approach. Carl, how did you approach your patiens on educating and discussing the vaccine with them?

00;13;53;17 – 00;14;09;23

Dr. Carl Lambert, Jr.

Yeah, I mean, I couldn’t agree more. I’m like I’m sitting here nod my head to everything that you’re saying. But I think one of the first barriers that I faced was like letting patients know that, Hey, this is an option for you. You’re not to be just counted out. Actually, the vaccine has you in mind as well, right?

00;14;09;23 – 00;14;26;03

Dr. Carl Lambert, Jr.

So there may be some extra steps, there may maybe some extra monitoring that’s involved or extra conversations. But again, a lot of times I had to convince patients that, hey, this is for you, too. This isn’t just for me or any other patient. This is also for you. And it can add extra protection that you particularly may need.

00;14;26;05 – 00;14;43;19

Dr. Carl Lambert, Jr.

Right. So a lot of times it was making a case with the patient that this is a good idea and not just to shut it down right away. And then also, to your point, being transparent and knowledge that it’s a decision that’s not to be taken lightly. So a lot of times of not going into the office visit and saying, are you going to do the shot or not?

00;14;43;19 – 00;15;00;23

Dr. Carl Lambert, Jr.

It’s more of a hey, let’s discuss this on an individualized basis. So, you know, I have several patients would say rheumatoid arthritis or lupus where we discuss like, OK, what would this look like for you in terms of getting the vaccine? Because we want to make sure that we keep you out of the hospital but you also don’t want to cause flares, right?

00;15;00;23 – 00;15;26;17

Dr. Carl Lambert, Jr.

So that’s where getting a third party like a specialist involved into that nuanced conversation can really be helpful and give that patient the confidence to move forward.  Again, like discussing risk versus benefits and then again being honest about, hey, this may require extra boosters down the line and letting them know like, hey, your response to the vaccine, even though you’re getting it, it may not be as robust as others hence is why you might need to get several more boosters down the line.

00;15;26;17 – 00;15;39;25

Dr. Carl Lambert, Jr.

So it’s a very deep conversation. It’s a continued conversation. It’s like a classic example of shared decision making, which is great to do. But I think the main tenet is just honesty and just facilitating trust with the patient every step of the way.

00;15;40;05 – 00;15;45;19

Dr. Christopher Smyre

I really like that. And then, Tim, how do you approach I think you have probably the most clinical experience out of the three of us.

00;15;45;26 – 00;16;15;25

Dr. Timothy Ott

Well, I think we’ve all lived through COVID but I’m in rural west central Illinois. And so I think my patient population and my approach might be a little different from you, too. I have encountered a lot of COVID denial and vaccine resistance in my patient population. And like you both have said, you know, this is a dance. You don’t want to try to force it down somebody’s throat.

00;16;15;26 – 00;16;41;19

Dr. Timothy Ott

You got to try to educate them and dance with them and hope that eventually they’ll see that you really believe in the vaccine and believe that it would be beneficial to them and that they will comply. And during the course of the pandemic, our recommendations change over time. So at first, the booster was only recommended for those mild the moderately immunocompromised patients to get the third shot.

00;16;41;19 – 00;17;12;21

Dr. Timothy Ott

And then we started saying, well, everybody should get the third shot. And those mild moderate people should maybe get a fourth shot, a second booster. And so trying to convince people that it wasn’t just me changing my mind that it was our knowledge of COVID that was evolving and our knowledge of the vaccine that was evolving and that I was trying to give them my knowledge of the most recent recommendations for the vaccine or for treatment.

00;17;13;03 – 00;17;38;2

Dr. Timothy Ott

And being rural, I think I probably have a little less ready access to specialists, as Dr. Meyer has over in Springfield and probably less than Dr. Lambert has. So if somebody is under active treatment for cancer, my approach is a little different. I tell them, yes, you should get the vaccine. And this is why. Ask your doctor if it’s OK for you to get the vaccine.

00;17;39;00 – 00;18;03;26

Dr. Timothy Ott

Don’t ask what they think about the vaccine. Just asked if it’s OK to get the vaccine. And so I try to convince them as much as possible without the specialist. But when I think they’re on medications that may make it not a good timing for the vaccine. Then that’s when I’ll get the specialist involved. But I do think it’s really important to build that confidence and trust with your patients.

00;18;03;26 – 00;18;10;05

Dr. Timothy Ott

And once you have that confidence and trust, then they’re much more likely to comply with your recommendations.

00;18;10;23 – 00;18;33;14

Dr. Christopher Smyre

Yeah, I think one of the things that I’m hoping you will take away from this conversation is that there are many different ways to approach and engage your patients in having these conversations. And you have to take into account the resource, the accessibility of how quickly and how easy it is for them to be able to see other specialists and also their own value system of what’s important to them.

00;18;33;14 – 00;18;53;06

Dr. Christopher Smyre

What are they really concerned about? Because what I’ve found is that once I understand what their values are and their priorities and fears, then I can provide the data that we know or be transparent, that there’s no concrete data. I can tell you to address this, but here’s the science or theoretically what we would expect and how we can plan around it so that they’re feeling really heard.

00;18;53;18 – 00;19;09;28

Dr. Christopher Smyre

And once we address their fears, and know their values, then they’re making a truly informed decision. At the end of the day, as physicians, that’s what we’re aiming for, for every patient, is that their choices are informed with the best evidence that we have at the time to choose what’s going to be in alignment with their own value system.

00;19;10;15 – 00;19;31;15

Dr. Christopher Smyre

But one of the other things that I found very helpful is actually on New Mexico Department of Health. They had to create this tool kit for immunocompromised and sort of thinking of like layering in different layers for protection. And so oftentimes as medical providers we talk about the Swiss cheese model and how usually if something goes wrong, there’s a lot of small holes within the system

00;19;31;15 – 00;19;55;23

Dr. Christopher Smyre

that  perfectly aligned to allow that error or near miss to happen. And one of the things that they talk about is different things we can do to sort of have different degrees of slippage and that we layer them in that we can basically block and prevent people being in the ICU and sort of dying from COVID. And so one of the big things they talk about is avoiding large gatherings and social distancing.

00;19;56;04 – 00;20;12;16

Dr. Christopher Smyre

That is really helpful because if you’re not around anyone, obviously you can get told it. But at the same time, we do know that during this period in this pandemic, there’s been a lot of isolation as cause depression. So there is that balance of making sure that how are we gathering and being able to connect with people, but doing that in a safe way.

00;20;12;29 – 00;20;50;06

Dr. Christopher Smyre

One of the other things they talk about is having early testing, early treatment and wearing your mask just to reduce the entry points into your own body, just to catch it sooner. Now that we have various medications that we can give to help expedite recovery and minimize symptom severity.  Thinking about it, finally, the vaccine itself, because if you’re vaccinated you have antibodies in your own system, even if for some reason you had all those other things in the whole system are aligned to get through the vaccine and has a huge amount of holes because you already have antibodies in your own system as that last final line of defense.

00;20;50;16 – 00;21;09;25

Dr. Christopher Smyre

And so what we hope you’ll take away from this and be able to take back to your patients who are immunocompromised, or if you’re listening to this as someone who is immunocompromised, either from something that you were born with, something that you’re on medication for another disease, or you have a disease that’s causing your immune state to be weakened, just know that you can still get the vaccine.

00;21;10;04 – 00;21;36;14

Dr. Christopher Smyre

Definitely talk to your own primary care provider and your specialists about sort of the risks and benefits for you and know that there are other options like Evusheld, if for some reason the vaccine wouldn’t be necessarily best for you when you look at the risks and benefits and that beyond the vaccine, wearing your masks, hand-washing frequently, social distancing will help reduce the likelihood and if we can do all these things together, then we can all be safe.

00;21;36;25 – 00;21;58;23

Dr. Christopher Smyre

And we can not only be safe for ourselves, but keep our loved ones safe. Because at the end of the day, no one wants to be the person who got it and then pass it on to someone they care for. And so this is not something that is only impacting us, but it also affects our loved ones. And like we discussed, a lot of ways that our immune system may be compromised or you may know people who have a weakened immune system for a variety of reasons.

00;21;59;05 – 00;22;06;19

Dr. Christopher Smyre

And the more that we can do to minimize the spread, to protect ourselves and protect others, the better we’re going to be as a whole country.

00;22;07;07 – 00;22;25;03

Dr. Timothy Ott

When I approached now, I said I have more vaccine resistance. When I see somebody that’s not vaccinated. My first approach is, like you said, to get to know the patient. And I just say, “Can you tell me why you’re not vaccinated? Can you tell me what your concern is? Can you tell me what your thoughts are on that?”

00;22;25;14 – 00;23;07;19

Dr. Timothy Ott

And then without being judgmental, just try to share some of the facts; like in our local hospital when it comes to people in the ICU on ventilators with COVID, it’s ten to one, that ten times more people that aren’t vaccinated than people that are vaccinated are the ones that end up in the ICU on the ventilator. So the vaccine is not perfect, but it certainly is a big help and without judging them for their thoughts or politics or religion, I’ll just try to share some of the facts and hope that they’ll hear some of the facts. And then just to plug the podcast series, I know there’s another podcast out there on COVID Therapeutics,

00;23;07;19 – 00;23;30;15

Dr. Timothy Ott

things you can do once you’ve got the COVID to try to prevent it from getting severe or prevent hospitalization. I participated in the development and recording of that one.  So that one’s out there. There’s also going to be a podcast about how to deal with the reluctant patient. So look for that one, too. So a plug a couple of our other podcasts.

Dr. Carl Lambert, Jr.

All right.

00;23;30;26 – 00;23;47;17

I don’t know if I have much else to add myself. I think you all have provided the mic drop for this episode, to be honest. But I would say to the listeners, just notice how we each kind of use the power of personal narratives here, right? So, it’s important to know the data, but also don’t be afraid to use personal narratives.

00;23;47;17 – 00;24;06;19

Dr. Carl Lambert, Jr.

I know physician endorsement of vaccines in and of itself is very helpful to move patients in the right direction to get the vaccine themselves. But oftentimes using personal stories with your patients, again, facilitates trust. And it conveys to them that you do very much still believe in the vaccine, that you’re not just pushing it, but you actually are coming from a place of concern.

00;24;07;09 – 00;24;14;25

Dr. Timothy Ott

Yeah, I got my mom or my daughter or my son vaccinated. I think that goes a long way towards that trust.

00;24;15;17 – 00;24;41;08

Dr. Christopher Smyre

So thank you once again, Tim. And Carl, for those listening. Thank you for listening to this podcast and the series that we’ve been doing. Definitely let us know if you have questions. We’re more than happy to try to connect you with resources, respond to those questions so that you can be encouraged, empowered and equipped with knowledge and the resources you need to continue to provide excellent care to your patients that you serve in your respective communities.

00;24;41;20 – 00;24;42;12

Dr. Timothy Ott

Thank you, everyone.

00;24;42;21 – 00;25;19;19

Dr. Carl Lambert, Jr.

Thank you

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