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Treatment

Explore COVID-19 treatment options with these AAAAI resources. Both patients and practicing allergist/immunologists can stay up to date on available treatment paths and make informed decisions for better patient outcomes.

The NEW recommendations for isolation are: isolate until 1) symptoms are improving over the last 24 hours, and 2) afebrile for the last 24 hours without medication. After isolation, additional precautions are recommended as outlined on this page: Respiratory Virus Guidance (cdc.gov) - March 1, 2024

These new guidelines apply to patients, not health care staff. CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings | Infection Control | CDC

Additional precautions: Risk Factors for Severe Illness from Respiratory Viruses | Respiratory Illnesses | CDC

There are treatments available for at-risk patients with mild-to-moderate disease that are safe and effective and should be considered. Here is a link for information for patients: COVID-19 Treatments and Medications | CDC and here is a link for physicians: Interim Clinical Considerations for COVID-19 Treatment in Outpatients | CDC

The FDA has granted an EUA for Pemgarda (pemivibart), a new long-acting monoclonal antibody for Pre-Exposure Prevention of COVID-19 in certain immunocompromised individuals. Pemgarda is authorized for individuals:
•    who are not currently infected with SARS-CoV-2 and who have not had a known recent exposure to an individual infected with SARS-CoV-2; and  
•    who have moderate-to-severe immune compromise due to a medical condition or due to taking immunosuppressive medications or treatments and are unlikely to mount an adequate immune response to COVID-19 vaccination.  
Here is the information from the FDA EUA page: Emergency Use Authorizations for Drugs and Non-Vaccine Biological Products | FDA - March 22, 2024

This Agency for Healthcare Research and Quality (AHRQ) Evidence Report evaluated 54 studies on adverse reactions to COVID-19 pharmaceutical treatments found little evidence of any serious adverse events associated with the use of antivirals or monoclonal antibodies with the possible exception of tocilizumab. Convalescent plasma was associated with an elevated risk of serious bleeding events and infection within 30 days. Adverse Events Associated With COVID-19 Pharmaceutical Treatments | Effective Health Care (EHC) Program (ahrq.gov) - March 6, 2024

In this randomized clinical trial of 1821 patients with mild to moderate COVID-19, among 1030 patients randomized in less than 72 hours of disease onset, a statistically significant difference was observed in the time to resolution of 5 COVID-19 symptoms between those who received ensitrelvir, (an oral SARS-CoV-2 3C-like protease inhibitor) 125 mg, and those who received placebo. Efficacy and Safety of 5-Day Oral Ensitrelvir for Patients With Mild to Moderate COVID-19: The SCORPIO-SR Randomized Clinical Trial | Infectious Diseases | JAMA Network – February 9, 2024

Data from the Veteran’s Health Administration from March-September of 2022 showed that utilization of an antiviral for 110 immunosuppressed patients was not even offered for 80% of the patients. For nearly one half of these, the only reason given for not offering antiviral treatment was mild symptoms. Other reasons included symptom duration >5 days (22.7%), lack of symptoms (22.7%), and concern about drug interactions (5.7%). One fifth of the 110 patients were offered treatment but declined. These treatments are safe and effective and should be used in most patients at risk for severe disease, regardless of the severity of symptoms at the time of encounter. Underuse of Antiviral Drugs to Prevent Progression to Severe COVID-19 — Veterans Health Administration, March–September 2022 | MMWR (cdc.gov) - January 25, 2024

A phase 2-3, DBPCRT showed that simnotrelvir, an oral protease inhibitor, combined with ritonavir reduced the time to improved symptoms by 36 hours compared to placebo when started within 3 days of symptom onset. Oral Simnotrelvir for Adult Patients with Mild-to-Moderate Covid-19 | NEJM - January 18, 2024

This updated review of rebound following the use of oral anti-virals for COVID, no association was found between treatment and rebound. The prevalence of rebound varied among studies depending on host factors and definition of rebound. SARS-CoV-2 Rebound With and Without Use of COVID-19 Oral Antivirals | MMWR (cdc.gov)   Similar SARS-CoV-2 RNA rebound rates were observed in nirmatrelvir/ritonavir and placebo recipients in two randomized, double-blind, clinical trials. Evaluation of SARS-CoV-2 RNA Rebound After Nirmatrelvir/Ritonavir Treatment in Randomized, Double-Blind, Placebo-Controlled Trials — United States and International Sites, 2021–2022 | MMWR (cdc.gov) - December 22, 2023

NIH Coronavirus Disease 2019 (COVID-19) Treatment Guidelines

National Institutes of Health (NIH) COVID-19 Treatment Guidelines

COVID-19 and Asthma: What Patients Need to Know (Reviewed June/29/2022)

Caring for Pregnant Patients With Asthma During the COVID-19 Pandemic (September/25/2023)

Neonatal respiratory distress has been reported in term, uninfected newborns whose mothers were infected with COVID-19 during pregnancy. This study using a cohort of mother-infant pairs in Los Angeles identified 221 mothers with laboratory-confirmed COVID-19 infections during pregnancy and 227 exposed fetuses. Unusually high rates of respiratory distress (17%) were observed in SARS-CoV-2 exposed but uninfected infants. The odds ratio for respiratory distress was 3.06 in term neonates born to unvaccinated individuals versus those born to individuals vaccinated prior to maternal infection. Respiratory distress in SARS-CoV-2 exposed uninfected neonates followed in the COVID Outcomes in Mother-Infant Pairs (COMP) Study | Nature Communications - January 24, 2024

Treating Your A/I Patients

This cohort study involving 68,867 patients at Cleveland Clinic with a diagnosis of COVID-19 from April 2022 until February 2023 who were at high risk for progression to severe disease. The use of nirmatrelvir or molnupiravir were associated with a reduction in hospitalization (OR 0.63 and 0.59 respectively) and death (OR 0.16 and 0.23 respectively). Nirmatrelvir or Molnupiravir Use and Severe Outcomes From Omicron Infections | Infectious Diseases | JAMA Network Open | JAMA Network - September 21, 2023

The American College of Physicians (ACP) has been providing a “Living, Rapid Evidence Review” on outpatient COVID-19 treatments and this is Version 2. Outpatient Treatment of Confirmed COVID-19: A Living, Rapid Evidence Review for the American College of Physicians (Version 2) | Annals of Internal Medicine (acpjournals.org) - September 19, 2023

A systemic meta-analysis of meta-analyses of azithromycin therapy for COVID-19 showed statistically insignificant reductions in mortality, need for ventilation, induction of arrhythmias and QTc prolongation. Clinical efficacy of Azithromycin for COVID-19 management: A systematic meta-analysis of meta-analyses - Heart & Lung: The Journal of Cardiopulmonary and Acute Care (heartandlung.org) - July 2023

For Patient Safety, It Is Not Time to Take Off Masks in Health Care Settings | Annals of Internal Medicine (acpjournals.org) - June 2023

The CDC on May 26 launched their new tracking dashboard, called RESP-LENS. This dashboard shows data on the number of positive tests for COVID-19, RSV and influenza who present to the ED. The data comes from over 100 hospitals in 20 states and should be useful for tracking these viruses in your area. RESP-LENS Interactive Dashboard | CDC - May 26, 2023

Caring for Pregnant Patients with Asthma during the COVID-19 Pandemic (Updated 9/25/23)

 

Dispelling Myths

Misinformation about COVID-19 is rampant, particularly on social media. Patients get mixed (and sometimes blatantly false) messages from news sources, family and friends. As our knowledge of the virus continues to grow and evolve, guidance from health experts changes, which leads to more confusion and suspicion. Here are some information and resources you can share with patients to help them sort through the misinformation.

Face Coverings

It has been demonstrated that wearing cloth face coverings combined with appropriate social distancing (6 feet) works to stop the spread of COVID-19. 

Hydroxychloroquine and Other False Medical Claims

There is no evidence to support the use of hydroxychloroquine for prophylaxis or treatment of COVID-19 as illustrated in these publications: 

Similarly, there is no clear benefit to the use of ivermectin or azythromycin for COVID-19. The FDA has additional information on why ivermectin should not be used for the prevention or treatment of COVID-19, and the references below provide additional details: 

People with allergic disease are not at higher risk for severe outcomes from COVID-19 due to a cytokine storm. Reports that patients with severe COVID-19 infection experience a cytokine storm are being extrapolated by some to infer that anyone with underlying ‘inflammation’, including allergic conditions, is at increased risk. There is no evidence to suggest that a patient’s allergic rhinitis, atopic dermatitis, chronic urticaria, food allergies, history of anaphylaxis, etc., places them at risk for severe outcomes should they become sick with COVID-19. 

Supplements or other holistic remedies cannot prevent or cure COVID-19. Claims of supplements, vitamins, or foods that ‘boost immunity’ are rampant, including from medical professionals and large healthcare organizations. Specific unproven COVID-19 treatments being promoted include essential oils, supplements, colloidal silver, Vitamin C, elderberry, homeopathy, and chiropractic adjustments. 

Allergists can help patients by guiding them towards these simple fact-checking questions for any claim: 

  • What are the qualifications of the person making the claim? 
  • What does the body of evidence demonstrate for both benefits and risks? 
  • Is the person making the claim directly profiting from services or products? 
  • How can this apply to my specific situation, including factors pertaining to my medical history and possible interaction with medications or underlying conditions? 
Asthma and COVID-19

The majority of evidence does not support asthma as a risk factor for becoming infected with SARS-CoV-2, and there are no data to suggest that, if infected, asthma patients have a more severe course of COVID-19 disease or will experience an exacerbation of their asthma. 

Asthma patients should be counseled that their inhaled corticosteroids are safe and necessary to continue use to prevent an exacerbation, and that systemic corticosteroids can and should be used to treat an asthma exacerbation even if it is caused by COVID-19. The studies showing a potentially worse outcome with systemic steroids were in hospitalized COVID-19 patients who received the steroids as a treatment for the viral illness and not for another disease. 

There is no evidence that the biologics we use in asthma have any adverse effect on COVID-19 cases, and it would be important to continue them based on the need for asthma control. 

You cannot catch COVID-19 from using a nebulizer, and patients that require treatment with nebulized medications should start treatment early and repeat until better. However, if a person with asthma who is receiving nebulized treatment has COVID-19, they could spread the virus to others in close proximity due to the respiratory droplets created through the nebulizer. 

Since October 2020, there have been over 120 publications including 4 meta-analyses that clearly demonstrate that asthma is not a risk, and at least a few have demonstrated protection for those with asthma. 

Children and COVID-19

Although children are less likely to get seriously ill from COVID-19, they can get sick and they are likely to spread the infection while asymptomatic. Here is some of the latest data:

  • Asymptomatic children with SARS-CoV-2 had Ct values (cycle threshold for RT/PCR) 10.3 cycles higher than children with symptoms (so less of a viral load). (J Clin Microbiol; Oct 22, 2020)
  • While children are less likely to be hospitalized for COVID-19 than adults, one in three hospitalized children are admitted to the ICU. Hispanics and Blacks accounted for the majority of hospital admissions and 42.3% had an underlying medical condition. (MMWR; Aug 14, 2020)
  • A large study including more than 5,700 COVID-19 patients in South Korea indicates that while children under 10 appear to transmit the virus less often than adults, adolescents and older children (age 10-19) transmit the virus at higher rates. (Emerg Infect Dis; July 16, 2020)
  • A team from Massachusetts General Hospital demonstrated that children infected with COVID-19, even those who are asymptomatic or with mild disease, have a significantly higher viral load than adults hospitalized with severe COVID-19. (J Pediatr; Aug 19, 2020)

Additional Resources

Misinformation about COVID-19 is also addressed in the following resources:

  • The Centers for Disease Control and Prevention now has a webpage called "Stop the Spread of Rumors" that lists known facts about COVID-19 and a social media toolkit with sample messages and graphics related to various COVID-19 topics for Twitter, Facebook and Instagram. 
  • The World Health Organization has a mythbusters webpage that addresses many common false claims about COVID-19.