Special consideration should be given to patients with asthma and those who are immunocompromised, according to a webinar updating the allergist community on patient management in the face of the COVID-19 pandemic that has been made available by the American Academy of Allergy, Asthma, and Immunology (AAAAI).
“What we know today is very fluid,” said webinar presenter Niraj Patel, MD, of Levine Children’s Hospital in Charlotte and UNC Chapel Hill. “This could and probably will change over the coming days and weeks the more we learn about the virus and how it is spread.”
Patients with asthma are at higher risk for severe disease from COVID-19, although it remains unclear if severity of underlying asthma plays a role, and there is no evidence to date that asthma is a risk factor for contracting the SARS-CoV-2 virus. Patients with asthma should be advised to continue to use their routine medications, including their inhaled corticosteroids, in order to prevent or reduce asthma exacerbations associated with viral infections. Similarly, biologic therapy should not be discontinued.
“Many of us have patients who are on oral corticosteroids routinely or who require oral corticosteroids, particularly for an acute asthma exacerbation,” said Dr. Patel. “For right now, the recommendation is to avoid them as much as possible, but in our field, when patients need oral corticosteroids, it is important to [use them to] treat the underlying issue, such as asthma.”
Patients with primary immunodeficiency as well as those receiving biologic or other immunosuppressants are likely to be at higher risk of contracting the SARS-CoV-2 virus. When possible, manage these patients away from the office with tools such as telehealth services. Recommend they follow all standard advice for risk avoidance, including staying home, not touching the face, washing hands, social distancing, and avoiding sick people. They should continue all current medications. If they do become ill, they should seek prompt medical evaluation.
The overall goal of the allergy practice is to minimize the spread of SARS-CoV-2, said Dr. Patel. In this light, consider adjusting office practice for allergy immunotherapy patients, including pre-screening them and considering dose adjustment (eg, less frequent or skipped doses) based on individual risk assessment. After treatment, it is reasonable to allow patients to wait in their car, if this is deemed safe.
Recently published research indicates that COVID-19 presents initially with mild symptoms in the first week, which includes fever (77%–98%), dry cough (46%–82%), shortness of breath (3%–1%), and myalgia or fatigue (11%–52%). In the second week, symptom severity worsens. For patients with allergic symptoms such as cough and rhinitis, the presence of fever can be a helpful indicator, said Dr. Patel.
Laboratory findings include lymphopenia in 70% of cases and eosinopenia in 52.9%. Chest radiography is not required for the diagnosis of COVID-19 but when they have been conducted, the x-rays most commonly reveal bilateral interstitial infiltrates. Very few patients have been found to have concomitant or subsequent bacterial infections.
Dr. Patel explained that coronaviruses belong to a ubiquitous family of viruses that, in humans, can cause respiratory tract infections ranging from common colds to severe respiratory infection and pneumonia. Most have an incubation period of 2 to 14 days (median 5–6 days), including SARS-CoV-2, the virus responsible for the disease known as COVID-19.
Symptom onset is 2 to 9 days post-exposure (median 5 days). Overall, about 80% of infections are mild, but up to 20% of patients will have more severe disease, with about 5% of cases being critical. In a recent study of 72 patients critically ill with COVID-19, the average age was 60, with a slight male predominance. The duration of symptoms to ICU admission was 9 to 11 days. Cardiac, liver, and kidney dysfunction were common, and mortality among those who became critically ill was 62%. Age over 65 and comorbidities were mortality predictors. Overall, 14% had hospital-acquired infections.
REFERENCE: Resources for A/I Clinicians during the COVID-19 Pandemic; https://education.aaaai.org/resources-for-a-i-clinicians/covid-19https://education.aaaai.org/resources-for-a-i-clinicians/covid-19