To the Editor:
Crees and Stockerl-Goldstein1 recently reviewed the management of light chain (AL) amyloidosis during the coronavirus disease 2019 (COVID-19) pandemic. While the literature discussed by authors is pertinent, certain lacunae in the diagnosis, prevention, and management need attention.
Monoclonal protein in AL amyloidosis could be secreted by either plasma cells or, rarely, B-cells.2 In addition to direct organ toxicity due to tissue deposition, monoclonal protein could cause 1) immunoparesis leading to increased risk and severity of infections, and an impaired vaccination response; and 2) coagulation disturbance leading to bleeding, thrombosis, or reduced antithrombin levels.3 COVID-19 has been associated with a potent thrombo-inflammatory milieu that causes thromboembolic complications.3 An overlapping multiorgan involvement in AL amyloidosis and COVID-19 has several implications with respect to the drug administration.3
In light of these observations and the current evidence, additional points are addressed below:
-
1.
Diagnostic challenges for AL amyloidosis during COVID-19.
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2.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) booster vaccination in patients with AL amyloidosis.
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3.
Management of indolent B-cell non-Hodgkin lymphoma-associated AL amyloidosis during the COVID-19 pandemic.
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4.
Management and response assessment in patients with AL amyloidosis infected with COVID-19.
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5.
Toxicity consideration of anti-COVID drugs in patients with AL amyloidosis.
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6.
Therapeutic implications of coagulation derangement of the 2 disorders.
These points are discussed in the Table 3, 4, 5, 6 under 3 heads: 1) management of AL amyloidosis during COVID-19 pandemic; 2) management of AL amyloidosis in patients with COVID-19; and 3) management of COVID-19 in patients with AL amyloidosis.
Table.
A Summary of Additional Management Considerations of AL Amyloidosis During COVID-19 Pandemic
| Management of AL Amyloidosis During COVID-19 | ||
|---|---|---|
| Comment (s) | Suggestion (s) | |
| Prevention measures | ||
| Prophylactic drugs3 |
|
Avoid using HCQ/macrolide prophylaxis for AL amyloidosis, particularly those with cardiorenal involvement. |
| SARS-Cov-2 vaccination3,4 | Rituximab causes prolonged B-cell depletion lasting 6-12 months after the last dose | Repeat SARS-CoV-2 vaccination at least 6-months after the last Rituximab dose |
| Booster vaccination (mRNA vaccines) could augment antibody response following the second dose in patients with hematological malignancies4 | Consider booster vaccination for patients with AL amyloidosis who have completed the 2-dose schedule. | |
| Nephrological considerations3 | Maintain COVID appropriate behaviour in the dialysis units |
|
| Diagnostic considerations3 | Avoid organ biopsies for the diagnosis of AL amyloidosis | Consider biopsy from alternate sites (abdominal fat pad) |
| Therapeutic measures | ||
| Treatment modifications3 | CyBorD |
|
| DARA-based regimens | Consider 90-minute IV infusion following an uneventful first infusion, particularly in countries where SC formulation is not available | |
| HSCT and renal transplant cause prolonged immunosuppression | Defer both autologous HSCT and renal transplant for patients with AL amyloidosis, if feasible. | |
B-NHL associated AL amyloidosis
|
|
|
| Management of AL amyloidosis in patients infected with COVID-19 | ||
| Therapeutic measures3 | Chemoimmunotherapy is potentially immunosuppressive |
|
| General measures3 | COVID-19 could cause cardiorenal decompensation in AL amyloidosis patients | Consider meticulous supportive care |
| Response assessment2,3 |
|
Re-evaluate for hematological and organ response after COVID-19 is cured |
| Management of COVID-19 in patients with AL amyloidosis | ||
| Anti-COVID medications3,5,6 |
|
|
| Hemostatic considerations3 |
|
|
AL = light chain; AT = antithrombin III; COVID-19 = Coronavirus disease 2019; CyBorD = cyclophosphamide, bortezomib, dexamethasone; DARA = daratumumab; HCQ = hydroxychloroquine; HSCT = hematopoietic stem cell transplant; IV = intravenous; LMWH = low-molecular-weight heparin; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; SC = subcutaneous.
Footnotes
Funding: None.
Conflicts of Interest: None.
Authorship: The sole author is responsible for all content.
References
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