key: cord-0963195-qpg3mv8g
authors: Chung, Kian Fan
title: Editorial More data on risks and outcomes of COVID-19 in asthma, COPD and bronchiectasis
date: 2021-04-26
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2021.04.031
sha: 5df44bd247031aec6fd46db534b13e2da4f06246
doc_id: 963195
cord_uid: qpg3mv8g

nan

respiratory disease (CRD) would be at greater risk of infection with more adverse outcomes from 31 SARS-CoV2 infection. A year on now, several observational studies have just been published that 32 brings some clarity regarding these risks with regards to asthma and COPD, and also bronchiectasis. 33 We start with the report from China published in the current issue in JACI: in practice (1), that 34 analysed the outcome of the 2.8% of the 39,420 laboratory-confirmed hospitalised patients with 35 COVID-19 who were diagnosed with CRD, using electronic medical records. More than half had 36 COPD followed by bronchiectasis and asthma. Patients with COPD and asthma were more likely to 37 develop more severe COVID disease by reaching a composite endpoint of need for invasive 38 ventilation, admission to intensive care unit, or death within 30 days of admission, after taking into 39 account confounding factors such as age, gender and presence of other co-morbidities. However, 40 these conditions were not associated with a greater likelihood of dying from COVID-19 compared to 41 those without CRD. 42

Two other large studies from the UK also using electronic medical records have just been 43 published. In the analysis of 75,463 hospitalised COVID-19 patients (2), 26.8% of patients had CRD 44 with 10.4% consisting of asthma and 13.6% with chronic pulmonary disease without asthma. This 45 proportion of CRD that is higher than the national UK prevalence for CRD indicate that the 46 susceptibility to catching COVID-19 was higher in this group. Although the latter group of 'chronic pulmonary disease without asthma' was not specifically described, the asthma group was sub-48 analysed in terms of age and asthma severity with a severe asthma category defined as those 49 prescribed with inhaled corticosteroid (ICS) plus a long-acting β-agonist (LABA) plus another 50 maintenance asthma medication. Patients with asthma aged above 16 years were more likely to 51 receive critical care than patients without an underlying respiratory condition, and those with severe 52 asthma aged 16-49 years had an increased mortality compared to those with no asthma. In patients 53 aged 50 years and older, use of ICS within 2 weeks of being admitted to hospital was associated with 54 a decreased mortality in those with asthma, compared to those without an underlying respiratory 55 condition. Patients aged 50 years or older with CRD (with or without asthma) were less likely than 56 those without a respiratory condition to receive critical care, but they had an increased mortality risk. 57

In another cohort study in England, general practice records of 14,479 people admitted to hospital 58 with COVID-19 out a population of 8.3 million people were analysed (3). While the prevalence of any 59 respiratory disease in that population was 15.4%, that in those hospitalised COVID-19-positive 60 patients was 25.5%. This risk of hospitalisation was increased in those with a diagnosis of asthma 61 (hazard ratio [HR] of 1.18) and was higher in severe asthma (HR 1.29) and COPD (HR 1.54). The risk 62 of death for severe asthma (HR 1.08) was increased but not in asthma (HR 0.99), and was higher in Two other studies in asthma have also been recently published. A study from Korea (5) 66 examined data taken from the National Health Insurance scheme of 7,590 COVID-19 patients of 67 whom 2.9% had asthma. They reported no association between asthma, asthma medication or 68 asthma severity and clinical outcomes of COVID-19, although there was in increased death rate in 69 the asthmatics compared the other COVID-19 infected patients (7.8% versus 2.8%). In a study from 70 Spain (6), the medical records of 1,006 COVID-19-infected people from a population of 71,182 71 asthma patients showed a higher prevalence of comorbidities such as hypertension, dyslipidaemia, 72 diabetes and obesity compared to those who were not infected. Those who were admitted to 73 hospital had more comorbidities. There was an increased mortality in the asthmatics with COVID-19 74 compared to non-asthma subjects with COVID-19. 75

Overall, these studies published this year indicate that asthma presents an increased risk of 76 COVID-19 infection with an increased propensity for more severe COVID-19 infection and for 77 increased risk of death in those with severe asthma, although this risk is not as high as that reported 78 for COPD. Two metanalyses of published studies conducted worldwide, reported in early 2021, 79 found no evidence of increased risk of diagnosis, hospitalization and severity, but with protective 80 effect on mortality from COVID-19 disease in patients with asthma (7, 8). However, a major issue 81 with this analysis is the tremendous heterogeneity of diagnosis and classification of asthma across 82 these different countries and the lack of detail on the asthma severity and treatments. These could 83 have contributed to these more reassuring observations, contrasting with the observations from the 84 large single country cohorts of China and UK as described above. 85

With regards to COPD, a Korean report using National Health Insurance scheme found a 86 with COVID-19 infection. In an analysis of the Korean National Health Insurance scheme, out of a 100 cohort of 8,070 COVID-19-infected patients, 132 (1,6%) had bronchiectasis against 1.4% in matched 101 cohorts with an increased 1.22 odds ratio of getting infected (11). These patients were older and 102 more frequently had pulmonary (e.g. asthma or COPD) and non-pulmonary (diabetes, hypertension 103 and heart failure) co-morbidities. They had more severe COVID-19 disease with a greater need for 104 supplementary oxygen, extra-corporeal membrane oxygenation and higher mortality. 105

For the management of these respiratory conditions that show different risk of worse 106 disease or even risk of death with COVID-19, it is important that their condition be optimally treated. 107

For asthma, particularly those with poorly-controlled asthma, management with ICS and LABA and 108 other medications should be maximised. There has been conflicting evidence regarding the 109 association of ICS treatment and outcome of COVID-19-infected asthmatic patients (good outcome: 110

(2, 6); poor outcome: (3, 4)) but observational studies cannot determine cause and effect. This 111 should not be used as an argument to limit the use of corticosteroids (both inhaled and oral) in 112 managing asthma. For those on biologic therapies targeting Type 2 inflammation, this treatment 113 may be associated with some protective effect on the clinical course of COVID-19 (6). Optimisation 114 of management of COPD and bronchiectasis also needs to be undertaken. Cigarette smoking or 115 secondary exposure to smoke should be discontinued or avoided. 116

With the increased risk of CRD patients catching COVID-19, it would be essential for these 117 patients to adhere to public health measures including physical distancing, regular use of face masks, 118 hand washing, avoiding crowded places and limiting meetings with groups of people. In fact, the 119 shielding policy adopted in various countries for those with at-risk diseases has helped to reduce the 120 prevalence of COVID-19 in these groups. But outside the shielding period these public health 121 measures need to be continued in this new era of co-existence with the SARS-CoV2 virus. Finally, 122 COVID-19 vaccination remains a priority and should be offered to this vulnerable group of CRD. It 123 might be argued, for asthma, that those with more severe asthma, particularly those needing regular 124 or continuous oral steroids or experiencing exacerbations, are most in need of vaccination, but this 125 would also be beneficial for the non-severe asthmatic. 126 127 J o u r n a l P r e -p r o o f

Chronic Respiratory Diseases and the Outcomes of COVID-19: A Nationwide Retrospective Cohort Study of 39,420 Cases. The journal 130 of allergy and clinical immunology In practice

COVID-19: a national, multicentre prospective cohort study using the ISARIC WHO Clinical 134

Characterisation Protocol UK. The lancet Respiratory medicine

Association 136 between pre-existing respiratory disease and its treatment, and severe COVID-19: a population 137 cohort study. The lancet Respiratory medicine

Risk of COVID-139 19-related death among patients with chronic obstructive pulmonary disease or asthma prescribed 140 inhaled corticosteroids: an observational cohort study using the OpenSAFELY platform. The lancet 141 Respiratory medicine

Effect of asthma and asthma 143 medication on the prognosis of patients with COVID-19

The impact of COVID-19 on patients with asthma

Asthma in Adult Patients with COVID-19. Prevalence and Risk 147 of Severe Disease

Prevalence of Comorbid Asthma and Related Outcomes in COVID-19: 149 A Systematic Review and Meta-Analysis. The journal of allergy and clinical immunology In practice

Impact of COPD on COVID-19 prognosis: A 152 nationwide population-based study in South Korea