Table 1 Consensus statements on the management of patients with MM and COVID-19 in the post-pandemic era.

MM and COVID-19

 • MM patients present an increased risk for severe COVID-19 infection, breakthrough infections, and poor COVID-19 outcomes including hospitalization and death, even in the era of novel SARS-CoV-2 mutants that produce milder COVID-19.

 • Main clinical risk factors for severe outcomes are older age, male sex, uncontrolled disease, multiple comorbidities, race/ethnicity, severe/critical COVID-19, ICU admission and low response to vaccination.

 • Specific anti-myeloma therapy, such as anti-CD38 antibodies and BCMA targeted therapy, increases the risk for severe COVID-19.

 • Overall, management of myeloma patients with COVID-19 has been improved since the outburst of the pandemic, resulting in lower morbidity and mortality.

MM and COVID-19 vaccination

 • Booster vaccines for SARS-CoV-2 should be administered to all patients with MM.

 • Variant-specific booster vaccines, such as the bivalent vaccine for the ancestral Wuhan strain and the Omicron BA.4/5 strains, are important for COVID-19 protection, as novel strains emerge and become dominant in the community.

 • Boosters should be administered 6–12 months after the last vaccine shot or documented COVID-19 infection (hybrid immunity). A 6–12 month interval between each booster dose is reasonable. It is unknown if boosters with the same vaccine are effective against the new virus strains.

 • If possible, vaccination should be performed before the initiation of B-cell depleting therapies (CD38- or BCMA-targeting treatments). Booster shots seem to overcome the negative effect of anti-CD38 monoclonal antibodies, but not of anti-BCMA treatments, on humoral responses.

 • Apart from active treatment with B-cell depleting therapies, risk factors for poor response to vaccination include older age, lymphopenia, immunoparesis and uncontrolled relapsed/refractory disease.

 • Autologous stem cell transplantation does not seem to exert a negative effect on immune response following vaccination, especially if the vaccine is administered at least 3 months post-transplant.

 • Evaluation of the immune response after vaccination may identify a particularly vulnerable subset of patients who may need additional boosters, prophylactic therapies and prevention measures. However, kits for neutralizing antibodies measurement against the new mutants are not commercially available.

 • Household members and healthcare professionals caring for patients with MM should be vaccinated according to the guidelines for the general population.

Pre-exposure prophylaxis for COVID-19

 • The combination of monoclonal antibodies tixagevimab/cilgavimab (Evusheld^®) is no more active against the widely prevalent Omicron subvariants BQ.1, BQ.1.1, BA.4.6. and XBB.1.5. Evidence is therefore lacking that Evusheld can effectively protect vulnerable adults against the current and anticipated variants over the next 6 months of SARS-COV-2 and is therefore not recommended for prophylaxis.

 • Immunoglobulin should be considered in patients with multiple episodes of recurrent/persistent infections and IgG levels less than 400 mg/ml.

 • Patients with MM are important to follow prevention measures during SARS-CoV-2 outbreaks including mask wearing and avoiding crowded places.

Treatment of patients with MM and COVID-19

 • Oral antivirals nirmatrelvir/ritonavir (Paxlovid) or molnupiravir (Lagevrio) can be offered to all MM outpatients with mild to moderate COVID-19 regardless vaccination or disease status, as soon as possible after the positive test for SARS-CoV-2 and within 5 days of COVID-19-related symptom onset. Careful consideration of drug interactions is essential. Nirmatrelvir/ritonavir is preferred over molnupiravir.

 • Remdesivir can be administered intravenously both in the outpatient and the inpatient setting. For patients who cannot receive nirmatrelvir/ritonavir, the use of remdesivir is recommended.

 • Oral antivirals and remdesivir remain effective against Omicron subvariants BA.2.12.1, BA.4, BA.5, BQ.1.1, XBB and XBB.1.5.

 • High-titer convalescent plasma may improve patient outcomes; however, it is extremely difficult to have convalescent plasma against the novel mutants and, thus, its value is debatable in the post-pandemic era.

 • Myeloma treatment should be interrupted and re-initiated upon symptom resolution.