**Disclaimer: I’m a patient, not a medical professional. Please do your own research, talk with your own healthcare providers, and understand that everything written below is based on my personal experience in the US as a single individual with a suppressed immune system. While I’ve made every effort to ensure the accuracy of the information shared (or to be transparent about which parts are speculation rather than hard fact), no responsibility is assumed for any errors. This post was last updated March 3, 2022.

Introduction to Evusheld

Two booty shots 🍑 💉💉, and your antibodies providing prophylactic protection against COVID-19 will skyrocket in minutes!

That’s more or less the premise of Evusheld for immunocompromised patients—at least, according to my cheerful nurse with the pink hair. I couldn’t actually track down a primary source to verify how quickly you’re considered to be protected; but given the injections dump a bunch of protective antibodies into your body, rather than attempting to mobilize your immune system to make them, it makes sense there’d be minimal delay. Maybe just the time it takes for the antibodies to move from your muscle into the bloodstream? I should stop my conjecture; ask your doctor if you want specifics.

The important part: patients with compromised immune systems can now receive an injection (well, two of them given within minutes of each other) that will provide greater protection against COVID-19 than receiving the vaccines alone—that is, if they can find a provider with supply. Note that it is different from other monoclonal antibodies like sotrovimab and REGEN-COV, which are used to treat COVID-19 infection as post-exposure prophylaxis. Evusheld recipients should not be currently infected with the virus.

Background information and how I came to receive Evusheld

My immune system is a fun little monster thanks to a mix of autoimmune encephalitis (AE) and the immunotherapies I’ve been on to curb it over the past 2.5 years. One of those therapies is rituximab (Rituxan), which latches on to the protein CD20 resulting in the destruction of the B cells necessary to create antibodies. So big fat surprise that 3 Pfizer vaccines failed to stimulate my immune system enough to produce a robust antibody/humoral response.

For patients like me, 12 years of age and older who weigh at least 88 lbs (40kg), AstraZeneca has developed a product called Evusheld. It’s two long acting monoclonal antibodies (tixagevimab and cilgavimab), co-packaged together and dispensed as two injections one after another, developed to provide pre-exposure prophylaxis against COVID-19 infection. I’ve heard it described as a “chemical vaccine” [1]. The US FDA granted emergency use authorization for Evusheld in December 2021, with the federal government now controlling its supply and distribution.

Note that so far Evusheld has yet to make it into wider global circulation, save for a handful of other countries like Singapore and Egypt. But that is steadily changing as it comes under investigation of more governments and regulatory bodies.

Different medical systems are using varying criteria to distribute their doses, as the number of eligible patients outstrips current supply. In the US, there are approximately 7 million immunocompromised people [2] and 1.7 million doses ordered, enough for 850,000 individuals, as of the time of writing [3]. In patient support groups, I’ve heard everything from recipient’s names being drawn lottery-style from a medical system’s internal list of immunocompromised patients, to doctors offering it to patients outright by virtue of the immunosuppressive treatments they’re on.

According to rheumatologist Dr Alfred Kim, an Assistant Professor of Medicine at Washington University School of Medicine in St Louis, Missouri, USA, where he founded and co-directs the Washington University Lupus Clinic, certain classes of medications interfere with the generation of an antibody response after COVID-19 vaccination, making patients susceptible to breakthrough infection. Medications that would make one eligible for Evusheld include:

1. high-dose steroids (e.g. ≥20 milligrams of prednisone or equivalent per day)
2. antimetabolites including methotrexate, sulfasalazine, leflunomide, mycophenolate
3. TNF inhibitors
4. biologic agents that are immunosuppressive or immunomodulatory e.g. B cell depleting therapies like rituximab [4]

Individuals who have had severe adverse reactions to the COVID-19 vaccine are also eligible under the emergency use authorization.

In my case, my neurologist told me in January 2022 that I did not qualify for Evusheld at his clinic because my SARS-CoV-2 spike antibody (IgG) results were positive after 3 Pfizer vaccines. Granted, the level came back at a number far lower than what they would expect from immunocompetent patients (who typically score numbers in the hundreds). While there are no consensus guidelines for quantitative interpretation of this result [5], he told me the “low positive” does suggest I mounted a humoral response to the vaccines—just not a large one. Alternatively, it’s possible these are from the monthly IVIG infusions I was on. But he had other patients deemed to be in greater need who test as having 0 protective antibodies, even after multiple vaccines.

Something changed in February, however. I lucked out; with multiple immunosuppressants active in my system, my name came up on a clinic-generated list and I suddenly had the green light to come in for Evusheld whenever I wanted. I jumped on that offer as soon as I could. Apparently I was the 4^th person to receive it at his office, with other eligible candidates being slow to snap up the supply…

You can read more straight from the official Evusheld website here: https://www.evusheld.com/

My experience receiving the injections

Word from the manufacturer indicates healthcare providers must administer 300 mg of tixagevimab and 300 mg of cilgavimab** as two separate consecutive intramuscular injections, each being in a volume of 3 mL [6] (for comparison’s sake, the Pfizer vaccine is 0.3 mL). Then individuals must be clinically monitored for at least 1 hour to ensure no hypersensitivity reaction or anaphylaxis occurs. My nurse said that rarely occurs, but that they have agents on hand such as epinephrine, steroids, and Benadryl should they be required.

**note that the FDA revised their emergency use authorization on Feb 24, 2022, and doubled the dosing amount of both antibodies from 150mg to 300mg due to data suggesting Evusheld is less effective against certain Omicron subvariants that were not in wide circulation when the first clinical studies were conducted. For patients who received Evusheld recently, prior to Feb 24: contact your provider as soon as possible to arrange another appointment to receive the remaining amount. Reference this FDA announcement [7] if necessary, as not all offices *cough* mine *cough* have been on the ball about dispensing the memo.

Practically speaking, most places will take you to a private room for a few minutes and give you one injection into each buttock. I’ve also heard the odd report of a patient receiving Evusheld into their upper arms—as with typical vaccines—but this seems to be rare practice. Pink-haired nurse guessed that the butt/gluteal muscles are used because they accommodate larger injectable volumes more easily than upper arm/deltoid muscles. Again, this is just more handwavy armchair expert-ing, so if you want firmer details ask your own doctor.

For the benefit of the unacquainted and slightly reluctant, who ducked out of taking anatomy in university (that’s me 🙋‍♀️): the gluteal muscle extends up higher than you might think. Yay—no awkward pull-your-pants-down maneuvers required! My nurse had me face a counter and lean forward on it slightly as she positioned the needle in an area on each side that *felt* more like my lower back. See syringe below for the injection site.

The injections stung for a few seconds and remained barely sore to the touch for a few hours; but other than that, everything was A-okay. Except for the fact that I accidentally broke my new keto diet in the absent-minded excitement of being offered animal crackers and ginger ale during the 1 hour observation period. Oops. Good start to having just entered ketosis….

Overall: no side effects, no soreness, no next-day malaise. I experienced nothing like the typical discomforts you expect with the COVID vaccine. This seems to be the experience of most Evusheld recipients, though keep in mind individual outcomes can vary.

Cost-wise, Evusheld itself is covered by the federal government. But in typical for-profit business, opaque, disordered medical system fashion, I was unable to determine whether I will incur a partial fee for administration. My insurance was billed but I could not get a concrete answer as to whether I would be seeing a co-pay bill in the mail later. But hey, I’m overjoyed to know that I’m better protected against COVID-19 now! Considering my experience with autoimmune encephalitis began 7 years ago much like the struggles now of those with long COVID, I’m a pretty happy camper.

My doctor advised me to hold off on a 4^th dose of vaccine for now, stating we would reassess what’s best for my individual situation in ~4-6 months. That’s how long I’ve been hearing that Evusheld is expected to remain effective, though the FDA has yet to issue official word on if/when repeat dosing will be needed. The tixagevimab and cilgavimab antibodies have been specially engineered to last more than 3x longer than normal antibodies (the monoclonals have half-lives of 87.9 and 82.9 days [6], respectively, versus ~23 days for IgG subclasses [8]), which dramatically increases their duration of activity within the body. Note your doctor may have a different vaccine recommendation for your specific clinical scenario.

Edit April 18, 2022: insurance processing is now complete and I was not deemed responsible for any additional costs. In general, this seems to be the norm for other patients I’ve heard from (though I’ve also seen the occasional person left with a co-pay, typically those with less comprehensive insurance plans). As far as protection, I had my spike antibody results retested a few weeks after receiving the top-up dose of Evusheld (pictured below). The results show a high titre, indicating that protective antibodies from Evusheld are now actively circulating in my system.

Now what?

If you’re immunocompromised, concerned about COVID-19, received suboptimal benefit from the vaccines, and want to be better protected against infection: consider asking your doctor whether Evusheld is a good option for you. It might not be—one contraindication is those with cardiovascular issues.

As of a few weeks ago when I conducted this *very* unofficial Instagram poll, few of my immunosuppressed friends said that they have even been offered this by their doctors. I suspect that’s largely due to constrained supply, with reward going to those who stay on top of this type of information and are willing to do the legwork to seek it out.

You can use the tools below to help you locate a place in the US that might administer Evusheld to you:

• https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com/
• https://rrelyea.github.io/evusheld/

To those pursuing this option: good luck and happy hunting!

References

1. https://spainsnews.com/evusheld-the-new-medicine-that-reaches-where-they-are-not-vaccinated 
2. https://www.cdc.gov/vaccines/acip/recs/grade/covid-19-immunocompromised-etr.html
3. https://www.astrazeneca-us.com/media/statements/2022/astrazeneca-to-supply-the-US-government-with-an-additional-one-million-doses-of-evusheld-long-acting-antibody-combination-for-the-prevention-of-covid-19.html
4. https://www.hmpgloballearningnetwork.com/site/rheum/videos/alfred-kim-md-covid-19-pre-exposure-prophylaxis-patients-autoimmune-disease?fbclid=IwAR2AY8R_Sw56B8GLW2VAfMc5YxPk_tFQJu-Ib9RHlXKPl4gFM9trC9clskc
5. https://www.medpagetoday.com/special-reports/exclusives/95156
6. https://www.fda.gov/media/154701/download
7. https://www.fda.gov/drugs/drug-safety-and-availability/fda-authorizes-revisions-evusheld-dosing
8. https://www.frontiersin.org/articles/10.3389/fimmu.2016.00580/full#:~:text=The%20pharmacokinetic%20profiles%20of%20antibodies,classes%20(18%2C%2019)

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