key: cord-0688165-dzatps7b
authors: Licskai, Christopher; Yang, Connie L.; Ducharme, Francine M.; Radhakrishnan, Dhenuka; Podgers, Delanya; Ramsey, Clare; Samanta, Tania; Côté, Andréanne; Mahdavian, Masoud; Lougheed, M. Diane
title: Key highlights from the Canadian Thoracic Society’s Position Statement on the Optimization of Asthma Management during the COVID-19 Pandemic
date: 2020-05-28
journal: Chest
DOI: 10.1016/j.chest.2020.05.551
sha: 3aca82ade716c005464bb24670fb7508a47a9405
doc_id: 688165
cord_uid: dzatps7b

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Conflicts of Interest: CL reports grants and personal fees from AstraZeneca Canada Ltd. (AZ), grants and personal fees from Boehringer Ingelheim Canada Ltd (BI), grants and personal fees from Novartis, personal fees from GlaxoSmithKline Canada Ltd (GSK), grants and personal fees from Pfizer, outside the submitted work. CLY reports grants and personal fees from Covis and Novartis, outside the submitted work. FMD reports unrestricted grants from Novartis, Teva, and Trudell Medical; grants from GSK and MEDteq in partnership with Thorasys Inc.; fees for consultancy work from Covis Pharma and Teva; and fees as invited speaker from Covis Pharma, Pharmacy Brunet, outside the submitted work. DR reports grants from CIHR, Children's Hospital Academic Medical Organization and Ontario Thoracic Society, outside the submitted work. DP reports speaker fees from AZ, outside the submitted work. CR reports fees for CME from Astra Zeneca and GSK outside of the submitted work. TS reports personal fees from Covis Pharma, outside the submitted work. AC reports grants from the Fondation Québécoise en Santé Respiratoire (FQSR), grants and personal fees from GSK, personal fees from AstraZeneca and Sanofi, outside of the submitted work. MDL reports grants from The Lung Association-Ontario, Ontario Thoracic Society, Government of Ontario's Innovation Fund, AllerGen NCE, Queen's University, Canadian Institutes of Health Research (sub-grant from the University of Ottawa), GSK, Hoffman LaRoche, Janssen, and Novartis; personal fees from The Lung Association-Ontario, and the Canadian Thoracic Society; and a grant and personal fees from AZ, outside the submitted work. MM reports personal fees from AZ, GSK and Novartis and a grant from Canadian Institutes of Health Research. This commentary summarizes the Canadian Thoracic Society's (CTS) position statement on managing asthma during the COVID-19 pandemic 1 in an easy FAQ format. The full asthma position statement as well as other valuable clinical tools including links to online self-management tools can be found at https://cts-sct.ca/covid-19/. In general, asthma maintenance and exacerbation management should continue according to national and international guidelines during the COVID-19 pandemic, however treatment decisions should be individualized based on patient characteristics. Optimal asthma control is expected to be the best protection against a SARS-CoV-2 exacerbation. 2, 3, 4, 5 The pandemic is a rapidly evolving situation. Healthcare professionals are advised to monitor the national/international society websites, including that of the CTS, for resources and links to asthma action plans and tutorial videos for children and adults on the proper use of inhalers and puffers as well as updates on COVID-19 and lung diseases. A link to recommendations regarding the clinical management of patients in the event of a Salbutamol MDI shortage can also be found on the CTS website https://cts-sct.ca/covid-19/.

No. Most studies to date suggest that asthma patients have no greater risk of acquiring COVID-19 than the general population. In the largest studies published to date with 44,672 patients (China) and 5,700 patients (United States of America) respectively, the prevalence of asthma in the COVID-19 population was below or approximated the expected general population prevalence; asthma patients were not over-represented. 6, 7, 8 Are patients with asthma at risk of having an exacerbation triggered by SARS-CoV-2 (COVID 19)? Probably yes, but there is no direct evidence. Viral respiratory tract infections are a common cause of asthma exacerbations. 9 Exacerbations requiring emergency department visits and hospitalizations increase annually at times when viral infections increase, typically week 38 on the calendar. 10 Nonpandemic coronaviruses have been associated with asthma exacerbations. 11, 12 Is asthma a chronic medical condition that is associated with a higher risk of severe illness or death from COVID 19? Possibly yes, but there is no direct evidence to answer this question. The Centers for Disease Control identify people with asthma as a group that may be at higher risk for severe illness from COVID-19. 13 While comorbid illness is common in people who are admitted to hospital and in people who die from COVID-19, asthma has not been identified as an independent risk factor for severe illness or death. Regarding severe illness leading to hospitalization, two studies from China, one from Korea, and one from the United States of America did not find that hospitalized patients with asthma were overrepresented in the COVID-19 populations studied. 8, 14, 15, 16 Regarding the risk of death from COVID-19, the Chinese Centre for Disease Control and Prevention reported a higher than average case fatality rate for patients with "chronic respiratory disease" but did not evaluate asthma as an independent risk factor. 7 In contrast, a report from Italy reporting 481 deaths and one from China reporting 54 deaths did not identify asthma as a co-morbid risk factor. 17, 18 Should asthma patients change treatment during the COVID-19 pandemic? No. Asthma patients should restart or continue their prescribed inhaled corticosteroid or inhaled corticosteroid steroid plus long-acting beta 2 -agonist maintenance therapy to improve disease control and to reduce the severity of exacerbations, including exacerbations that may be caused by SARS-CoV-2.

So far, yes. There is no evidence of harm caused by using prednisone to treat asthma exacerbations during the pandemic. The brief course of prednisone used to treat acute asthma exacerbation is not expected to compromise the immune system enough to increase chances of acquiring SARS-CoV-2 and/or developing COVID-19. Patients should use prednisone to treat severe asthma exacerbations, whether or not the exacerbation is triggered by SARS-CoV-2.

Yes. There is no evidence that inhaled corticosteroids increase the risk of acquiring COVID-19 or that inhaled corticosteroids increase the severity of infection. Most importantly, inhaled corticosteroids are key to maintaining disease control in most patients with asthma, and well controlled asthma is probably the best protection against a SARS-CoV-2 virus induced asthma exacerbation.

Yes. Biologics are not expected to adversely affect the immune response to viral infection. In fact, Omalizumab may protect against viral-induced exacerbations. 19 Patients should continue using anti-IgE, anti-IL5, and anti-IL4/IL13 monoclonal antibodies during the COVID-19 pandemic since they reduce the frequency of severe asthma exacerbations and therefore, the likelihood of entering the health care system. (Note: anti-IL4/IL13 monoclonal antibody therapy is not currently approved in Canada for the management of severe asthma)

No, except for patients who are unable to use a metered dose inhaler with a spacing device or a dry powder device. Nebulizers may increase the risk of aerosol spread of virus particles and the risk of infection for healthcare workers and caregivers. 20 The recommendation to avoid nebulization applies to all patients, not only to patients that have confirmed or suspected COVID-19. Patients should continue using or switch to metered dose inhalers with spacing devices, or dry powder inhalers to administer inhaled-corticosteroids and short-acting bronchodilators. For patients unable to use a metered dose inhaler with spacing devices, or a dry powder inhaler, nebulizers may be used cautiously in compliance with applicable contact and droplet infection control standards.

Yes. Asthma patients should follow current local, national public and global health advisories on physical distancing and isolation. Patients should work from home, if possible. If not possible, patients with severe asthma should stay away from work until the World Health Organization or local public health authorities declares that physical distancing is no longer necessary or appropriate work accommodations can be made.

Addressing therapeutic questions to help Canadian physicians optimize asthma management for their patients during the COVID-19 pandemic

Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention

Recognition and management of severe asthma: A Canadian Thoracic Society position statement

Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults

Diagnosis and Management of Asthma in Preschoolers: A Canadian Thoracic Society and Canadian Pediatric Society position paper

Do chronic respiratory diseases or their treatment affect the risk of SARS-CoV-2 infection?

China Center for Disease Control and Prevention's emergency response mechanism for coronavirus pneumonia epidemiology team. Epidemiological characteristics of new coronavirus

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area

The role of viruses in acute exacerbations of asthma

Prevalence and contribution of respiratory viruses in the community to rates of emergency department visits and hospitalizations with respiratory tract infections, chronic obstructive pulmonary disease and asthma

Regional, age and respiratory-secretion-specific prevalence of respiratory viruses associated with asthma exacerbation: a literature review

Centers for Disease Control & Prevention. Groups at Higher Risk for Severe Illness

Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan

Clinical Characteristics of Coronavirus Disease 2019 in China

COVID-19) Outbreak in the Republic of Korea from

Characteristics of COVID-19 patients dying in Italy

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Effects of Omalizumab on Rhinovirus Infections, Illnesses, and Exacerbations of Asthma

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1