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Member Question: I have a patient recently diagnosed with CVID. She has no ability to make antibodies at all, and is now receiving IVIG. For COVID-19, even if a vaccine becomes available in the fall, are there any antiviral medication regimens you would recommend at this juncture to utilize prophylactically or maintain on standby if required?
Expert Answer: At this point there is no proven effective therapy for COVID-19. There are a number of clinical trials ongoing. Social isolation is key in this setting. Anti-COVID 19 IgG will eventually make its way into IVIg materials, but this will take several years at a minimum. This is a very difficult problem. You will also find information on this topic in the Special Article: COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic

Member Q: Given concerns about infectious disease during the current COVID-19 outbreak, there has been discussion in some quarters about changing allergy immunotherapy protocols using glycerinated/aqueous extracts to a standard maintenance interval of six weeks or more. The discussion stems from proposed efforts to reduce patient visits to physician offices to reduce potential waiting room exposures among patients.

What is the thought among members of the immunotherapy practice parameter workgroup on this proposed change in practice? Would we expect a recommended interval of six weeks to be both safe and effective for most patients? Are there thoughts about waiting room transmissibility of common respiratory pathogens incorporated in the existing guidelines?
Expert A: Please refer to the current CDC guidelines on COVID-19 mitigation in healthcare settings for the most up to date information. 

One will still need to consider the overall risks and benefits of administering immunotherapy on an individual basis for each patient. 

Given the current concerns about COVID-19, recommendations to practice social distancing and the need to minimize elective encounters, it is a very valid question and the resulting actions may help mitigate risks of infectious disease transmission in this pandemic. The current practice parameters do say that maintenance IT can be given every 2-6 weeks, customized to the patient. Thus, for most patients, (and again, it should be tailored to the patient) the frequency of subcutaneous aeroallergen immunotherapy during maintenance, can safely be extended temporarily to meet that time frame. Of course during build up phase, this may not be the same, as the safety of building up doses with a longer intervals is not usually recommended. However, as with pregnant patients on build up, it may be okay to not increase IT dose but increase the interval (i.e., decrease the frequency) temporarily until they deliver or in this case, the concerns about infectious transmission abates.

Member Q: There is some concern about oral corticosteroid consumption in patients with asthma attacks due to COVID-19.
Expert A: The use of systemic corticosteroids for treatment of COVID-19 lung disease in individuals without asthma is not recommended. There is no data at this time to support not using all standard asthma therapeutic measures, including systemic corticosteroids, in individuals with asthma and a COVID-19 infection. Patients with asthma should continue to take their controller medications and not stop them, even if they have symptoms of COVID-19. Also, 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. Patients with asthma need to continue to take their controller medications and keep their asthma under control because the risk here is that they stop the medications, have an asthma flare, then have to go to the emergency department because they have respiratory symptoms in an area with known community spread of COVID-19, and then they get COVID-19 from being in the emergency department—all of which could have been avoided by keeping their asthma under control in the first place.

Member Q: Given concerns about infectious disease during the current COVID-19 outbreak, there has been discussion in some quarters about changing allergy immunotherapy protocols using glycerinated/aqueous extracts to a standard maintenance interval of six weeks or more. The discussion stems from proposed efforts to reduce patient visits to physician offices to reduce potential waiting room exposures among patients.

What is the thought among members of the immunotherapy practice parameter workgroup on this proposed change in practice? Would we expect a recommended interval of six weeks to be both safe and effective for most patients? Are there thoughts about waiting room transmissibility of common respiratory pathogens incorporated in the existing guidelines?
Expert A: Please refer to the current CDC guidelines on COVID-19 mitigation in healthcare settings for the most up to date information. 

One will still need to consider the overall risks and benefits of administering immunotherapy on an individual basis for each patient. 

Given the current concerns about COVID-19, recommendations to practice social distancing and the need to minimize elective encounters, it is a very valid question and the resulting actions may help mitigate risks of infectious disease transmission in this pandemic. The current practice parameters do say that maintenance IT can be given every 2-6 weeks, customized to the patient. Thus, for most patients, (and again, it should be tailored to the patient) the frequency of subcutaneous aeroallergen immunotherapy during maintenance, can safely be extended temporarily to meet that time frame. Of course during build up phase, this may not be the same, as the safety of building up doses with a longer intervals is not usually recommended. However, as with pregnant patients on build up, it may be okay to not increase IT dose but increase the interval (i.e., decrease the frequency) temporarily until they deliver or in this case, the concerns about infectious transmission abates.

Member Q: Regarding COVID-19 and the use of a nebulizer in a clinic setting and the risk for spreading of the virus, are there institutional guidelines for use of a nebulizer? Given the data of suggested transmission in the in-patient setting, should we eliminate use of the nebulizer in the clinic? (And not just in an A/I division, but a pulmonary lab where they use for PFTs, family practice, internal medicine, pediatrics, UCC, etc.)
Expert A: The CDC considers the use of a nebulizer as a procedure that can generate aerosols that contain respiratory secretions. Therefore, for a patient with COVID-19 the CDC recommends the healthcare worker wear a full PPE (gown, gloves, eye protection, and a respiratory—note a PPAR or N95 respirator is much better than just a facemask*) when having close contact with the patient while they are getting a nebulization. This is for a known COVID-19 patient. There are no clear guidelines for suspected or unknown COVID-19 patients. At this time, I would screen for COVID-19 and if the screen is negative, then would not have problems with using a nebulizer. However, if the screen suggests a need for testing (i.e., appropriate travel history or exposure to COVID-19 patient, since the patient already has shortness of breath—at least I’m assuming that is why the nebulization is needed), then I would act as though the patient were infected with SARS-CoV-2 and wear full PPE as mentioned above.

*The CDC considers it high-risk to be exposed to a COVID-19 patient getting nebulizer therapy with no PPE; however, the use of all PPE but a facemask rather than a respirator only reduces the risk to medium level (not low). So it is important to use a respirator (N95 or PPAR) if at all possible.

Member Q: To the best of our knowledge, it is advised to short term step-up therapy in asthmatic patients during viral infections. Regarding the epidemy of COVID-19, do you advise this strategy for asthmatic patients who are compromised with COVID-19 or not?
Expert A: The management of asthma exacerbations in individuals with COVID19 is the same as with any other virally induced asthma exacerbation.

Member Q: We are currently in the process of establishing protocols for screening potential COVID-19 patients in our practice. We currently have several hundred asthmatics in our practice. The typical symptoms for COVID-19 of cough, shortness of breath, and fever could be very similar to an asthmatic having a viral induced exacerbation. Would PF meters help sort out? What if no PF meter available? Would there be a significant downside of giving OCS or high dose ICS to known asthmatic patient who also has COVID-19? 
Expert A: The current continually updated recommendations for COVID-19 screening and management are available at the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html.

At this time, management of virally-induced asthma exacerbations from COVID-19, or any other respiratory virus, remain the same.

The current critically important COVID-19 mitigation measures for patients with asthma, and everyone else, to adhere to are:

1. social distancing
2. frequent hand washing
3. keeping one's hands out of one's face

There are no data on whether SARS-CoV-2 (COVID-19 virus) causes asthma exacerbations. In fact, in the available published data from China it appears that asthma is under-represented in the hospitalized COVID-19 patients, which may suggest protection rather than risk (but take this statement with a large grain of salt). Nonetheless, other coronaviruses can exacerbate asthma (and asthma is over-represented in MERS-CoV infections), so it is plausible that SARS-CoV-2 will cause asthma exacerbations. Having said that, as mentioned above, the treatment of an asthma exacerbation, regardless of etiology, is the same—so if you would normally increase inhaled steroids or add systemic steroids, you should do the same even if the patient has COVID-19.

Member Q: Multiple patients being treated for asthma with various biologics (Dupixent, Nucala, Xolair) are asking if they should stop biologics in light of possible COVID-19 infection.
Expert A: Given that respiratory viruses, including rhinoviruses, influenza, and COVID-19, are triggers for asthma exacerbations, all currently prescribed effective anti-asthma therapy, including all FDA approved anti-asthma biologics, should be continued in patients with asthma. Frequent hand washing, keeping the hands out of the face, and social isolation are also essential factors in helping to mitigate COVID-19 spread. 

Again, it is not known how the IL4, 5, 13, and IgE systems operate in COVID-19 disease. It is more important to keep asthma under control, and if a biologic is required for that control, then it should be continued. As mentioned, in all other respiratory virus infections that associate with asthma exacerbations, the recommendation is to continue the biologic, so again, that would be the advice for COVID-19.

Member Q: Is there anything we should know in regards to immunocompromised patients since they are in a high-risk category when it comes to COVID-19?
Expert A: The published data from China has very few immunodeficient patients included in their cohorts, for example, out of 1,066 hospitalized there were two, and they had non-severe disease (NEJM 2020. DOI: 10.1056/NEJMoa2002032). Nonetheless, it makes sense that patients who have compromised immune systems will be at risk of a more severe infection, if they get COVID-19. The importance here is to prevent infection in the first place. As has been said numerous times, the best approach at this time is for these patients to: (1) practice social distancing (avoid crowds and travel, keep at least six feet away from anyone who appears ill or has a risk factor [in the past 14 days either travel to China, Japan, South Korea, Italy, Iran, Europe (except the United Kingdom) or symptoms of lower respiratory infection]), (2) frequently wash their hands with soap and water for 20 seconds, and don’t touch your face, (3) continue any medications for their underlying health conditions, and (4) call before going to any healthcare provider (including emergency department and urgent care). The last issue is important because providers need to make sure that when an immunocompromised patient comes to their office they are not exposed to potential COVID-19 patients. Providers should keep a close eye on their own health and take appropriate precautions to not become infected with SARS-CoV-2, and to stay at home should they exhibit signs of COVID-19.

Member Q: I just had a patient come in with flu symptoms, but could it be COVID-19? What do you recommend for possible exposures?
Expert A: This is very much an evolving space. The response depends in part on the level of community spread going on in your location. If you are in an area without community spread, then you need to assess for other risk factors—especially, in the 14 days before the onset of symptoms did the patient have a history of travel to China, Iran, Italy, Japan, Europe (except the United Kingdom at this time), or South Korea (CDC level 3 countries; level 2 country travel should be included, as well, but the CDC just made the entire world level 2 for “older adults or those with chronic medical conditions”; see this page) or close contact with someone who has laboratory confirmed COVID-19. If the answer to either of these questions are ‘yes’, then the patient should be screened for COVID-19. In an area with community spread, the above questions become less helpful. In that case, it certainly could be COVID-19 (although it could also be the flu, although the flu activity is just starting to decrease). Unfortunately, there really aren’t any good discriminators between COVID-19 and influenza (at least at this time).

For possible exposures, refer to the CDC website. This website has a good risk assessment tool that provides guidance for healthcare workers who have had differing levels of potential exposure to a COVID-19 patient.

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