20 Comments

Thank you, I enjoyed listening to your podcast, great format. Hadn't realised importance of IgA in preventing infection getting hold in first place, long before CD8 or even IgG called in to play.

Valid point re access to treatments.

Amazing to think less than 2 years into pandemic, the world has a choice of vaccines, antibodies and small molecule antivirals to choose from. Now we just have to share them between us...

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I agree. I should do a newsletter on monoclonal antibody technology. One of the most significant things invented by man.

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Nov 15, 2021Liked by Gavin Giovannoni

Yes please! A brief history would be great & humanizing it all would be lovely. 1974-today!! who and what… I work for an academic medical center - cancer center … significance of this is amazing. Nice visual historical timeline here - only thru 2019, but the idea is there…. https://jbiomedsci.biomedcentral.com/articles/10.1186/s12929-019-0592-z

For Cancer, MS, so many applications & now Covid …. Over 40 years of hard work and research + science

I’d love to read/listen to a newsletter if you do one. As always, thank you…

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Nov 21, 2021Liked by Gavin Giovannoni

Thank you, this post is really helpful.

I am wondering about whether to get the Moderna booster, given that I had my last Ocrevus infusion in late July and that my CD19 count is currently 0.

I had my second Ocrevus infusion in early October 2020, followed by two doses of the Pfizer vaccine in March. I failed to seroconvert. In consultation with my neurologist, I postponed my third Ocrevus infusion, scheduled for early April, and got a third Pfizer dose in early June (my CD19 count had risen to 2.1%). After the third dose, I was able to seroconvert and had high antibody levels according to blood tests in late June, early August and early November.

I got my third Ocrevus infusion in late July. A few days ago, a new blood test showed that my antibody level had fallen a lot (to a relatively low level) compared to early November (!), and that my CD19 count was 0% (as one would expect given that my last infusion was in late July).

Given this context, would you recommend getting the Moderna booster?

My reasoning is that the booster could potentially help, and that there is not much downside to getting it. Is this reasoning sound? My idea is that I could again delay my next Ocrevus infusion, scheduled for late January, by one or two months so as to achieve some B cell repletion, then get another booster in February or March, and hopefully seroconvert then.

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I agree. It seems as if this is your booster of 4th dose. In the UK you would be recommended to have this 5-months after your 3rd dose. But if you want to maximise your response waiting for some B-cell reconstitution would make sense.

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Prof. G., I wanted to flag the following very good news in case you and your patients/readers have not yet read about it:

https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-authorizes-astrazenecas-covid-19-antibody-drug-2021-12-08/

"The U.S. Food and Drug Administration on Wednesday authorized the use of AstraZeneca's (AZN.L) antibody cocktail to prevent COVID-19 infections in individuals with weak immune systems or a history of severe side effects from coronavirus vaccines.

The antibody cocktail, Evusheld, is only authorized for adults and adolescents who are not currently infected with the novel coronavirus and have not recently been exposed to an infected individual, the regulator said.

The authorization for the therapy, made up of two monoclonal antibodies tixagevimab and cilgavimab, marks a significant step for AstraZeneca, whose widely used COVID-19 vaccine is yet to be approved by U.S. authorities.

AstraZeneca last month had agreed to supply the U.S. government with 700,000 doses of Evusheld, which had earlier shown to cut the risk of people developing any COVID-19 symptoms by 77% in a late-stage trial."

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Thank you. If I get the 4th dose now (i.e., the booster shot, more than 5 months after my 3rd dose), do you think it would be possible and safe for me to get a 5th dose in March, after I have had some B-cell reconstitution?

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Nov 13, 2021Liked by Gavin Giovannoni

Loved everything about this - so much so I sent it to my oncologist friend/colleague who educated me on “prophylaxis” & covid + my MS scenario (Ocrevus) just last night - On what it is, what it means and what is available now and on the horizon.

I am wondering if Roche, who is the parent company for this treatment and for Ocrevus , is planning to advise for those on ocrelizimab …. ?

Adding the audio was incredibly helpful and your podcast tone/style really works beautifully….

Thank you for the education & for posting/creating with panache …!

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Nov 12, 2021Liked by Gavin Giovannoni

I am biased.

I agree we should use the mabs for treatment of acute cases - for vaccinated patients.

After that, vaccine non-responders (or the rare few who truly cannot take the vacine) should get them as prophylaxis. I have very little patience for the unvaccinated by choice these days.

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Sorry, but I can't support your position.

As a doctor when you take the Hippocratic oath you promise to look after anybody and everybody with a medical need to the best of your ability.

Please note vaccine hesitancy is a very complex issue and the reasons for not having vaccines differs from one group of people to another group. Rather than ostracise people who decide not to get vaccinated we should be supportive, particularly when they may need us most.

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founding
Nov 13, 2021Liked by Gavin Giovannoni

I am aware I am biased.

The way I see it, their refusal to get vaccinated (around here mostly for reasons out of spite, not reasons like lacking language skills) increases risks for vaccine non-responders like me, resulting in me having to wear FFP2 masks wherever I go and avoiding restaurants etc. So to me it is personal.

FWIW, somewhat related, where do you stand on boosters in Europe vs using the same doses for initial vaccination in developing countries?

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Nov 14, 2021Liked by Gavin Giovannoni

Provide yourself with some peace in your heart with these oft quoted words:

God grant me the serenity

to accept the things I cannot change;

courage to change the things I can;

and wisdom to know the difference.

Take out religion if that is your penchant, but loving acceptance of others is the basis of humanity.

You have chosen to be protected by the vaccine, trust in your choices.

Accept other’s choices as they accept yours.

Or as is said in more modern speak- You do You 😉

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Nov 12, 2021Liked by Gavin Giovannoni

I'm sure you have it right with current real-world constraints. But I am curious: Assuming a situation where supply wasn't an issue, do you think doctors and regulators will agree that anti-body PrEP for immunocompromised/sero-non-converting is warranted/justified/worth the $$? I have this dream that in a year or so I will be able to get an infusion that makes me (fingolimod, no Abs after 3x Moderna shots) similarly safe to vaccinated healthy people.

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Yes, and no. I prefer the option of a combination of small molecule inhibitors used in at-risk time rather than monoclonals. The widespread use of these monoclonal antibodies is just going to select for escape variants.

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Nov 12, 2021Liked by Gavin Giovannoni

Maybe not an answer I'm excited about, but good to hear the argument for both sides :) Thanks for the response.

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Way to kick a man when he is down!

I was with this post (and all ProfG does, as a paid subscriber) until the last paragraph and name-calling/shaming of a patient. Where is the compassion? The empathy for obvious anxiety? Don’t we want to support patients who are pro-active in their health decisions, not belittle their possible WRONGTHINK?

This patient is sincerely concerned about his lack of protection despite his best efforts. Offer him some preventative measures in case he must go out in public:

Salt water with 15ml hydrogen peroxide and 4 drops of iodine (salt solution: 15-20ml of salt to 8-12oz water). Gargle and spit prior to contact with public or 3x/day in early Covid.

A nasal drop solution of 1% iodine (mix 5ml iodine into 50ml dropper bottle. Fill with distilled, sterile or previously boiled water) To use tilt head back, apply 4-5 drops to each nostril. Keep tilted for a few minutes, drain.

Zinc Citrate 50mg (6= 100mg elemental zinc)

Vitamin D3 5,000IU (or more if deficient)

Vitamin C 3,000-8,000mg daily in divided doses

Quercetin 500mg twice daily (take with Vit C for best absorption)

Melatonin 5-10mg at bedtime

Curcumin 500-1000mg twice daily

EGCG 400mg in the AM

Using Aspirin 81-325mg daily (if able) to prevent early clots should they occur with the vaccine or early infection

All these are over the counter in the US. I am unsure of what you have there. But if you have, at minimum, access to iodine you can make the first two. That will kill and prevent the virus in your nose/mouth. Those steps with hand washing and distancing as much as possible will help tremendously.

At the very least a provider should offer some basic tactics to ease a patient’s troubled mind.

I truly regret feeling compelled to post the above. I was completely shocked by the shaming of a shut-in, concerned patient- needlessly. This felt like a personal attack of someone who may have just needed updated information. Up until the last paragraph I felt educated by multitude of new information here.

This seems out of character for you ProfG- and for that I am grateful. We become accustomed to your caring attitude and informative style.

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Nov 15, 2021Liked by Gavin Giovannoni

One more thing... Quercetin should NEVER be taken by someone who is on a blood thinner for clots.. it actually will decrease the effectiveness of the blood thinner. Same thing will happen if you eat foods containing high levels of this like apples and certain types of grapes.. Yes this supplement fights inflammation, but again, you need to check with your doc before you just go start taking anything.. Including aspirin, zinc, iodine, etc.. sorry but yeah, these things can be dangerous when mixed with certain other drugs..

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Yes, good point. Many health supplements contain substances that are bioactive and interfere with metabolism. Always check before you start taking anything.

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Not sure if you interpreted my response correctly. All I said is that we are unable to prescribe Ronapreve prophylactically in the UK at the present time (NHS and private sector). Things may change when the supply of the product increases. It is about rationing, which to the best of my knowledge is also happening in the US.

Not sure if we have any strong evidence that iodine nasal drops prevents COVID-19. There is data the virus is inactivated by iodine in the lab, but there is a data gap regarding clinical practice. Need to be careful as a significant number of people are allergic to iodine solutions.

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Melatonin is contraindicated with many drugs. Some are MS DMTs.. best to double check that one before just starting on something like that or any other drug or supplement without checking for interactions. You need to make your docs aware that you are taking this or any other supplement. Just because you can buy it OTC doesn't mean its harmless because this one can interact with many other drugs that are prescribed.

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