Evusheld Guide

Tips and information to help immunocompromised get the covid protection they need.

About This Guide

We wrote this guide to help people who need Evusheld or think they might. The guide explains how Evusheld works and who needs it, and gives you some relevant background on immunity and on what causes people to be immunocompromised. And it gives practical advice on figuring out whether you qualify for Evusheld, finding a supplier and convincing a doctor to prescribe it for you.

At the end of the guide are links to some scientific and medical articles that explain these matters in more detail, for those who are interested. The articles there are some of the ones we read in order to write this manual. While we are not scientists or doctors ourselves, we do have training in statistics and research design, and read up on Evusheld, COVID-19 and immunity so that we could give you accurate information. And we consulted with an oncologist, a biologist who is herself taking immune-suppressing drugs, and a person who has a PhD in pharmacology. The information here is good. If you have suggestions or questions about the content, please email: evusheld-data@relyeas.net

ABOUT EVUSHELD

What is Evusheld?

Evusheld is a medication that gives people whose immune system isn’t working well some extra protection against covid. Most people’s immune systems produce antibodies when they get the covid vaccine, and the antibodies, along with some other blood cells, work to fight off the virus if the person gets infected. But people with suppressed immune systems do not make antibodies, or do notmake enough of them when they are vaccinated. Evusheld gives them a supply of long-lasting antibodies. It is given as 2 injections right in a row on the same visit. You need to have a prescription from a doctor to get it. 

Evusheld gives protection that lasts for about 6 months. It depends partly on which new COVID variants are dominant. Evusheld reduces the chance of hospitalization for COVID by about 80%. Most doctors recommend that Evusheld should be given in addition to COVID vaccinations and boosters. (Evusheld can’t be given at the same time as a vaccination. You need to wait at least 2 weeks after a vaccination or booster to get the Evusheld shots.) The combination of Evusheld and vaccination can often make an immunocompromised person about as protected as a normal person from becoming severely ill if they become infected with COVID.

Evusheld was initially given an Emergency Use Authorization on December 8, 2021. On June 29, 2022 it revised its recommendation to include repeat dosing of Evusheld every 6 months for those who qualify for the drug. The FDA is monitoring the performance of Evusheld against new variants, and believes it is currently still effective against the COVID variants that are circulating.

Evusheld sometimes has side effects, and it may not be a good idea for people with certain medical conditions to receive Evusheld. Here is a link to more information about Evusheld from the FDA (Food and Drug Administration).

Who needs Evusheld?

Two kinds of people need Evusheld: people who are unable to get the COVID vaccines because of allergic reactions, and people who are immunocompromised. If you are in the first group, a lot of this manual does not apply to you. You can skip ahead to the “How Do I Get Evusheld” section, and look through our site’s information about places in your state with available Evusheld. When it comes to convincing a doctor to give you Evusheld, the doctor may or may not agree. If you are young and in good health, the doctor may feel that your chance of severe illness from COVID is low, even if you are unvaccinated. Older people, and younger ones with risk factors (asthma, obesity, diabetes, etc.) who are allergic to the vaccine may have an easier time getting a doctor to give them Evusheld.

Most people who need Evusheld are not allergic to the vaccine, but are immunocompromised. “Immunocompromised” means their immune system does not work well. It doesn’t do a good job at fighting real infections, and does not make enough antibodies when the person gets vaccinated against an illness. (Sometimes people use the terms “immunosuppressed” or “immunodeficient.” They all mean pretty much the same thing.) There are two main things that can lead to someone being immunocompromised. They can have a disease or condition that keeps the immune system from working right. Or, they can be having treatment for another disease, and the treatment itself suppresses the immune system.

For more info about being immunocompromised, have a look at this Wikipedia article.

Wouldn’t my doctor have told me if I needed Evusheld?

Not necessarily. There have been a lot of things about the way Evusheld has been introduced that have led to doctors not offering it to some people who need it. It was shipped out in a hurry, and not well-publicized. And Evusheld was not shipped directly to doctors — your doctor does not have any at the office. Some doctors do not know a lot about exactly who qualifies for Evusheld and how much is available. Some doctors are so busy they have not had time to contact all the patients they have who qualify for Evusheld. So we recommend that you do your best to figure out on your own whether you qualify, then contact your doctor if you think you do. If your doctor has told you in the past that you are unusually likely to get infections, that probably means that the doctor thinks you are immunocompromised. If the doctor has not said that, we recommend that you read what follows to try to get an idea whether you are. 

You could try just skipping the research and asking your doctor whether you are immunocompromised and need Evusheld. However, we have heard a lot of stories from people who did that and were told by their doctor that they did not qualify or that there was no Evusheld available. So we think it is better to be prepared in advance with information about why you may qualify, and how much Evusheld is available near you, so that when you talk to your doctor you are all set to make a good case if you meet opposition.

How do I know whether I am immunocompromised enough to need Evusheld?

The truth is, there is a lot of uncertainty among doctors regarding this exact question. Some are not clear about the guidelines the CDC (Center for Disease Control) and FDA (Food and Drug Administration) have given regarding Evusheld. Others are, but see that there are a lot of judgment calls to be made regarding who, exactly, qualifies for Evusheld. If a doctor has told you you do not qualify for Evusheld they may or may not be right. Then again, they may be uninformed about the guidelines, or informed but just making a different judgment call than another doctor would. In this section we are going to fill you in as well as we can about the guidelines and some of the judgment calls involved. Unless you already know for sure that you are quite immunocompromised and qualify for Evusheld, you should look at them. We are sorry to be giving you all this medical information to wade through, but if you are going to advocate for yourself you need to have it.

The FDA Criteria:The FDA states that Evusheld is to be given to people who are “moderately or severely immunocompromised.” It then spells out in some detail who these people are. Table 1, below, shows the current FDA criteria.

TABLE 1: QUALIFYING FOR EVUSHELD - FDA CRITERIA

Quoted from www.fda.gov/media/154703/download as of 6/15/2022.

We believe the FDA guidelines are the information you should show to your doctor. Doctors take government guidelines seriously. However, these guidelines are not very user-friendly, so Table 2, below, presents the guidelines broken down a little bit more for you, and with some further details about the illnesses and treatments on the list. The FDA guidelines also have a footnote adding that qualifying conditions “are not limited to” those on the table, and Table 2 also adds to the FDA list three additional conditions that we believe likely qualify people. 

Finally, Table 2 contains information from an NIH (National Institute of Health) publication that gives criteria for who among the moderately and severely immunocompromised should be given priority if there was very little Evusheld available. There is not, currently, a shortage of Evusheld – in fact one third or less of the supply has been given to people in the six months the drug has been available. But we think it is useful for you to have information regarding which immunocompromising conditions the government regards as most serious.

TABLE 2: QUALIFYING FOR EVUSHELD - FDA CRITERIA (DETAILS AND EXTRA CRITERIA ADDED BY US)

Details in Bold identify conditions that appear on the NIH “short list” of conditions that give people extra priority if the supply of Evusheld is extremely limited.

Anything in italics was added by us.

Some criteria we have added

• Liver cirrhosis. See this qxmd.com article, which found that people who have liver cirrhosis respond poorly to vaccinations, and do not develop much immunity from vaccinations for covid.

Sources:

Notice that aside from a few illnesses (blood cancer, immune deficiency diseases, advanced HIV) a lot of what qualifies people is drugs that suppress the immune system. Cancer treatment qualifies people because many (though not all) of the drugs used in treatment suppress the immune system. Recent stem cell procedures or organ transplants qualify people because both require the use of particularly powerful immune-suppressing drugs. And the final item on the FDA list of qualifying conditions is a list of classes of drugs that suppress the immune system. So let’s talk about these drugs, and whether the drugs you are taking suppress your immune system enough so that you need Evusheld.

Using drugs that suppress the immune system: It might seem like a bad idea to give somebody a drug that suppresses the immune system, but there are situations where the advantages are bigger than the disadvantages. People who have had organ transplants take immune-suppressants to keep their body from rejecting the new organ. Some cancer treatments suppress the immune system, but are needed to fight the cancer. And some people with auto-immune diseases do better if they take a drug to damp down their immune system. Auto-immune diseases are diseases where the body attacks some of its own cells the way it would attack such enemies as viruses and bacteria. Immune-suppressing drugs slow down the body’s attack on its own cells, but also make the immune system less able to fight off real enemies, such as COVID.

If you are reading this manual, it’s likely you are someone who is being treated for cancer or for an auto-immune disease. Below is a table listing the most common auto-immune diseases, including information about the drug classes most commonly used to treat them. There are many autoimmune diseases besides the common ones appearing on our table. If you have an auto-immune disease, a doctor has probably told you that you do.

TABLE 3: COMMON AUTOIMMUNE AND INFLAMMATORY DISEASES AND DRUGS USED FOR TREATMENT

Diseases often treated with B cell-depleting agents or steroids are in *bold with a star next to them. Diseases often treated with other immune-suppressing drugs, but not with B cell depleters or with steroids are in bold.

*Addison’s Disease

Autoimmune Vasculitis 

*Celiac Disease

*Crohn’s Disease

Dermatomyositis

Diabetes, Type 1

Grave’s Disease

Hashimoto’s thyroiditis

*Lupus

*Multiple Sclerosis

*Myasthenia Gravis

Pernicious Anemia

*Psoriasis/psoriatic arthritis

*Rheumatoid Arthritis

Scleroderma

Sjogren’s syndrome

*Ulcerative Colitis

Sources:

Notice that some of these conditions are commonly treated with immunosuppressive drugs, and others, such as Type 1 Diabetes, are generally not. (Of course, there are exceptions to this generalization. There may be doctors who try treating something like Type 1 Diabetes disease more aggressively, using immunosuppressants rather than the usual approach.) If you have an autoimmune disease that is not treated with immune-suppressing drugs, there is no reason to think your immune system is working less well than anyone else’s. You probably are as able to benefit from the COVID vaccines as someone who does not have your condition. It is also good to keep in mind that there are certain autoimmune diseases for which doctors often use particularly aggressive immune-suppressing treatments. Our impression is that Multiple Sclerosis, Rheumatoid Arthritis and Lupus generally get the most aggressive treatment.

Like treatment of autoimmune diseases, cancer treatment sometimes uses immunosuppressive drugs and sometimes does not. If you have cancer but are not taking an immune-suppression drug, your body can probably do a good job of building immunity to covid when you were vaccinated.

Different classes of immune-suppressing drugs: Table 4, below, lists drugs in all of the drug classes mentioned in the FDA guidelines. The first three classes on the table, Bruton Tyrosine Kinase Inhibitors, B cell-depleting drugs and high-dose steroids seem to be the ones the makers of the government guidelines see as most immunosuppressive – each is singled out in some way in the guidelines. Because of their special importance, we made an effort to include in the table every single drug in these classes. As for the other classes, we went with some lists we found online. These lists may not be complete. If you are taking a drug that does not appear on our list, you can google it and the information you find about the drug will likely tell you what class it falls into.

TABLE 4: DRUGS THAT SUPPRESS THE IMMUNE SYSTEM

Bruton Tyrosine Kinase Inhibitors:Especially powerful immunosuppressants used for treating some forms of leukemia and lymphoma

B Cell-depleting Agents:Powerful immunosuppressants used for cancer and autoimmune disease

Steroids:Used for inflammatory and autoimmune disease to reduce inflammation or to suppress the immune system

Alkylating Agents:Used in cancer treatment.

Antimetabolites:Used for both cancer and autoimmune disease

Transplant-related immunosuppressive drugs:Used for transplants and for autoimmune disease

TNF Blockers:Used for autoimmune disease

Other immunosuppressive drugs:

Sources

How much immunocompromise is too much? There has been a lot of research into how effective covid vaccination is for people who are immunocompromised for various reasons. We read some of it, and also two excellent, very thorough summaries of the literature. They are:

Here are the three main takeaways

We hope that all this information, taken together, helps clarify for you whether you are immunocompromised, and if so how badly. Here’s a summary: You are likely to be significantly immunocompromised if you have a primary immunodeficiency disease, if you have some form of blood cancer, if you have untreated or advanced HIV, or if you had CAR-T, an organ transplant or a stem cell transplant in the last couple of years. For everyone else, it depends on what drugs you are taking. If you are taking Bruton Tyrosine Kinase Inhibitors orB-cell depleting drugs (those are the ones in the top two groups in Table 4) you are probably significantly immunocompromised. If you are taking high-dose steroids, you may also be. If you are taking anything else, you may have some degree of immunocompromise, but it is not as likely to be severe. If your degree of immunocompromise is not severe, you may be adequately protected just by getting an extra vaccination on top of the usual series, although for that too you need to qualify. Here are the government recommendations for vaccination schedules for the moderately and severely immunocompromised.

 But bear in mind that the summary we just gave is actually much more conservative than the FDA guidelines. According to the FDA guidelines regarding drugs, people taking any of the drugs on Table 4 qualify for Evusheld. So if you would like to err on the side of caution and get Evusheld, even though the immune suppressants you are taking are not among the most aggressive ones, it certainly appears that you qualify. It is, though, our impression from talking to doctors that some might turn you down for Evusheld even though you are taking certain of the immune suppressants. They might, for example, say you are taking too small a dose of the drug to be very immune suppressed, or that you have not been taking it long enough. They might recommend that you simply stop taking the immune-suppressing drug for 2 weeks before getting vaccinated, and not resume it until your body has had time to respond to the vaccine by building immunity. (And that, in fact, is a perfectly valid strategy, if it is safe for you to just discontinue your immune-suppressing drug for that period.) We think, though, that doctors are much less likely to turn you down if you are taking Bruton Tyrosine Kinase Inhibitors, B cell-depleting drug, or steroids at the doses given in the table. 

Is there a shortage of Evusheld?

A lot of people are immunocompromised. Of course, some might not want to get the Evusheld shot. If we use a conservative estimate of how many immunocompromised people there are, and aim to protect half of them with Evusheld, we would need 4 million doses of the drug. The US government has about 875,000 doses of Evusheld from the manufacturer. Thatis only enough for one person in 5 out of the 4 million we’d hope to protect with Evusheld. So yes, there is nowhere near enough to go around. On the other hand, the amount that’s available is being given to the public very slowly. Pharmacies and other sites have received a total of 361K doses since January of this year. Even though the drug has been available for almost six months, only about 150K doses of the supply had been given to patients as of this writing, at the middle of June 2022. The rest is on shelves waiting to be used. So few patients know about Evusheld, and so few doctors are well-informed about it, that the supply we have is in danger of going to waste.

Here are 2 articles about the problems with getting Evusheld to the people who need it. (The second one also covers distribution problems with other COVID drugs, but gets to the subject of Evusheld in the second half.)

Under the circumstances we think it is legitimate and not selfish to try to get Evusheld if you are immunocompromised. You will not be taking it away from somebody else. You will be taking it out of storage.

How much does Evusheld cost?

The drug itself is free. There often is a charge for administering it, which most insurance should cover.

HOW DO I GET EVUSHELD?

Look over the sites near you that have it

Our website is set up to help you locate all the Evusheld providers near you. You will be able to see how much Evusheld each one currently has. We think the site is pretty user-friendly, but here are some instructions. If you don’t feel like you need help using the site, go ahead and use the dropdown menu on the main page (covidsafe.fyi/evusheld) to look at providers in your state.

To start, go to the main page of this site: covidsafe.fyi/evusheld. To see info for your state, click on the bar at the top of the page that says <state>. A list of all the states will appear, and you can select yours. Or, you can click on your state in the US map on the main page.

Here’s the information you’ll see at the top of the page after you pick your state. We picked New Jersey for our example.

If you click on one provider you get taken to more information about it.

You can see from the graph that Hackensack U Medical Center got a shipment of 200+ doses of Evusheld on 2/15 and another 60 or so on 2/22. Their inventory dropped over the next couple weeks, then on 3/8 they restocked. If you want to see how much they had on one particular day, hover the cursor over the graph at any point. Above, we hovered it over the graph on 3/31. In the future, we hope to be able to give you a clickable link to the website of each provider, and also a phone number. Unless that info appears on the page, though, you will have to google Hackensack U Medical Center yourself to get the information.

There is also a questionnaire at the bottom of the page where you can tell about your experience with this provider, to help other searchers. We hope you will fill it out! We will not share your name or your email address.

Figure out the lay of the land in your state

Look over all the sites in your state. Evusheld was shipped to a lot of different kinds of places. Some of those are more likely than others to be willing to give you a dose. Most hospitals and outpatient clinics have Evusheld, but they often give it out only to people who are already patients at their institution. Many pharmacies and infusion centers have it, and those places are usually more willing to give doses to anyone who walks in, provided their doctors send them a prescription for you to get it. And there are some sites with odd names and it is not clear what sort of place they are. If you have an affiliation with a hospital or outpatient clinic, they are likely to be your best bet. But if you do not, pharmacies and infusion centers are the most promising.

Call some sites near you

If, wherever you call, you reach someone who seems never to have heard of Evusheld, ask to speak with the pharmacist or the person who handles medications. If you call a hospital’s main number, ask for the pharmacy or the infusion center. If you call a drug store, ask for the pharmacist.

We suggest you say something like this: “I have learned that I am eligible for Evusheld. I am calling around to help my doctor locate a place that will give it to me. Would it be possible to come to your site to get the shots?” 

Try to keep going until you find a place that says they will give you Evusheld. If you absolutely cannot find one, you can go to the next step, contacting your doctor, and hope the doctor knows of a place to send you. Some do. But it is better to go to the doctor with the name and contact information of a place that will give you the med. It makes things easier for the doctor, and it also serves as proof that it actually is possible to get Evusheld (some think there is almost none available, or that it’s all in hospitals being saved for transplant patients).

Contact your doctor

The ideal thing would be to meet with your doctor in person to discuss Evusheld. If it is possible to get an appointment some time in the near future, we recommend that you do that. If not, you need to speak with your doctor directly. If your doctor uses a patient portal, or has given you their email address, you can send them a detailed message (we give a sample one below.) If you need to contact them by phone, tell the receptionist that you have an important question having to do with your ability to withstand infection. (If you must, you could even sort of imply you are ill now — though not with Covid — and feel like you are not fighting off the bug.) If you get connected to the office nurse, tell her the same, but you can add that you are interested in getting Evusheld. Unless she says “fine we’ll give you some,” push to speak with the doctor.

Sample Letter to Doctor

Dear Dr. ___________,

I recently learned that I may qualify for Evusheld. I know that it is only given to those who are moderately and severely immunocompromised, but I did not know what illnesses and medications make people immune compromised. But it appears from what I have read that I do qualify, because of [name the illness or immunosuppressive drug you think qualifies you]. Here is a bulletin from the FDA that lists the thing that qualifies me: www.fda.gov/media/154703/download. There is also an FDA site with detailed information for providers about Evusheld, covering dosage, handling, storage, contraindications, special populations, etc. It is here: https://www.fda.gov/media/154701/download  The government has also set up another page for providers that allows doctors to order a si ngle dose of Evusheld, and gives them the number of a provider helpline where they can ask AstraZeneca any questions they have. (The provider page is at https://aspr.hhs.gov/COVID-19/Therapeutics/updates/Pages/important-update-27July2022.aspx. The phone number for the helpline is 1-833-388-7453.)

Also, I had heard that there is almost no Evusheld available, and that it is being saved for the sickest of the sick. However, it looks like Evusheld is being distributed very slowly, and there is quite a bit of it currently available. Here is an article about that: As New Variant Spreads, a Crucial Drug to Protect the Most Vulnerable Goes Vastly Underused (statnews.com)

Then, if you have located a site that will give you Evusheld, say this: I have searched on the government’s Covid-19 Locator and found a place that will give me the injections. It is [name & address of the place]. 

If you have not located a site that will give you Evusheld, say this: I have searched on the government’s Covid-19 Locator but have not yet found a place that will give me the injections. I am hoping you know of a place that provides injections. If you do not, I will keep looking until I find one, to spare you the trouble.

Either way, end the letter or email in some friendly way, saying you hope to speak with the doctor soon, and giving a phone number and times when you are reachable.

Talking with your doctor

When you speak with your doctor, start by just saying you believe you qualify for Evusheld, and asking the doctor about getting the injections. Don’t sound irritable and resentful, even if you feel that way — be polite and friendly. Hopefully your doctor will agree. If they do not, their objection will probably be one of three things: You are not immune compromised enough; there is not enough Evusheld available; or they are not comfortable prescribing Evusheld because they are not very familiar with it and have not used it before.

The information at the FDA site (www.fda.gov/media/154701/download)  really does cover all the things a doctor would want to know. There are many pages of details. It covers dosaging, dosing schedules, special dosages for certain populations, possible bad reactions to it, whether and how to use it with certain populations (pregnant, elderly, people with kidney disease, etc etc.), how to store and handle Evusheld, and so on. You could even consider printing out the whole thing and presenting it to your doctor. The unusual thing about Evusheld is that doctors did not hear about it the way they do about other new drugs. Usually there are presentations and mailings by the pharmacy companies for doctors to attend where they learn about new drugs. That did not happen with Evusheld, and so for many doctors it’s kind a spooky unknown – they feel uneasy about prescribing it. Handing the doctor a sheaf of pages telling them everything they might want to know about Evusheld might just do the trick. (On the other hand, it might irritate them . . . You make the call, taking into consideration what your doctor is like.)

Fallbacks if your doctor says no

If your doctor says that you do not qualify for Evusheld, listen carefully to their explanation and make notes on it. You need to consider the possibility that the doctor is right. For instance, even if you are taking one of the immunosuppressive drugs listed on Table 4, it may be that you are taking an unusually small dose, so small that it is unlikely to make any difference in your ability to develop COVID immunity from the vaccinations. They are other valid reasons, as well, why you might not qualify.

But if you are sure you qualify, here are some further steps to take:

LET US KNOW HOW IT WENT

We hope our information and suggestions helped you get Evusheld, and we would like to hear how it went. We will pass any information you give us on to other patients (but we will not share your name or email address). We would especially like to know what worked and what did not work for you, and any suggestions you have for people in addition to the ones we give. You can send the information to:covid-data@relyeas.net

GOOD SOURCES OF INFORMATION

Here are some articles and websites where you can get further information. They include all the places we linked to in the manual, and some additional recommendations as well.

The big picture about Covid, immunity, vaccines and other medications

Autoimmune disorders

Immune-suppressing drugs

How immunocompromised people respond to vaccination

Evusheld and how it works

The Evusheld distribution problem

Government publications