This page compiles our content related to Management of coexisting conditions in the context of COVID-19. For further information on diagnosis and treatment, follow the links below to our full BMJ Best Practice topics on the relevant conditions and symptoms.
Introduction
Considerations for perinatal care
Considerations for newborn care
Considerations for patients who require anticoagulation
Relevant conditions
go to our full topic on Acute kidney injury
Patients with COVID-19 may develop acute kidney injury (AKI). Age ≥60 years and severe COVID-19 are independent risk factors for mortality.[69] Patients who have severe COVID-19 are more likely to require continuous renal replacement therapy compared with patients who have nonsevere COVID-19. AKI significantly increases the risk of in-hospital death in patients with COVID-19.[69] One cohort study of patients with in-hospital AKI in the US found that COVID-19-associated AKI was associated with a greater rate of estimated glomerular filtration rate decrease after discharge compared with AKI in patients without COVID-19, and this was independent of underlying comorbidities or AKI severity.[70]
UK guidelines note that in people with COVID-19, AKI can develop at any time (before, during, or after hospital admission), and that maintaining euvolemia (optimal fluid status) is critical to reducing AKI incidence.[66]
The treatment of AKI in patients with COVID-19 appears to be the same as in other populations, including continuous renal replacement therapy if necessary.[71] Medications that can cause or worsen AKI should be stopped unless essential. Some treatments for COVID-19 may increase the risk of AKI.[66] Patients with elevated body temperature and increased respiratory rate will have greater insensible fluid losses.[66] Intravenous fluids are required in many cases, and choice should be guided by biochemistry. The goal of intravenous fluid therapy is to maintain a euvolemic state.[66] Potassium binders can be used as part of the emergency management of life-threatening hyperkalemia, alongside standard care.[66]
go to our full topic on Acute lymphocytic leukemia
Analysis of US health-insurance claims data has shown that leukemia is a significant risk factor for fatal COVID-19.[72] An international expert panel and the American Society of Hematology have made recommendations for the treatment of adult acute lymphocytic leukemia.[73][74] Clinicians should consider minimizing corticosteroid exposure and reducing doses of daunorubicin and pegaspargase (pegylated asparaginase) during treatment induction in older people and people at high risk for complications of COVID-19.[73][74] Anti-CD20 monoclonal antibodies reduce immune globulin levels; treatment with these agents should be deferred if possible. Second-generation tyrosine kinase inhibitors with reduced-dose corticosteroids should be considered in Philadelphia chromosome-positive disease.[73][74]
Clinicians should consider blinatumomab if patients are positive for minimal residual disease after two cycles of chemotherapy. If patients are negative for minimal residual disease and have received most of their chemotherapy, they may be advanced to maintenance. During maintenance, clinicians should consider reducing corticosteroids and avoiding vincristine in patients >65 years. Recommendations are given for relapsed or refractory disease and transplantation. Growth factor support should be considered in patients without COVID-19 to facilitate neutrophil count recovery and maintain absolute neutrophil count above 1000 cells per microliter during all phases of treatment. Growth factors should probably be avoided in patients with moderate-to-severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection because there is a potential risk of exacerbating inflammatory pulmonary injury.[73]
There are limited data on trials of SARS-CoV-2 in patients with hematological conditions. Such patients are likely to have an attenuated response to vaccination. One study of the BNT162b2 mRNA COVID-19 vaccine in patients with hematological malignancies found the antibody response was reduced compared with healthy controls, and was affected by disease treatment.[75] Additional measures, such as early vaccination of household contacts, may be considered.[76]
go to our full topic on Acute myelogenous leukemia
Analysis of US health-insurance claims data has shown that leukemia is a significant risk factor for fatal COVID-19.[72] Acute myelogenous leukemia (AML) is associated with worse survival in patients with COVID-19.[77] Patients with AML should be screened for COVID-19 before starting induction or consolidation chemotherapy.[78] Patients receiving intensive therapy should, ideally, be barrier nursed in a COVID-19-negative ward with enhanced screening and protection measures. Chemotherapy should be delayed until the resolution of symptoms and the patient has a negative polymerase chain reaction test. Cytogenetics and nucleophosmin-1 (NPM1) and fsm-related tyrosine kinase-3 (FLT3) status will guide choice of chemotherapy. Venetoclax and gilteritinib have been granted emergency approval from NHS England for use in selected patient groups.[78]
Growth factors should probably be avoided in patients with moderate-to-severe COVID-19 because there is a potential risk of exacerbating inflammatory pulmonary injury.[73]
There are limited data on trials of severe acute respiratory syndrome coronavirus 2 vaccination in patients with hematological conditions. Such patients are likely to have an attenuated response to vaccination. One study of the BNT162b2 mRNA COVID-19 vaccine in patients with hematological malignancies found the antibody response was reduced compared with healthy controls, and was affected by disease treatment.[75] Additional measures, such as early vaccination of household contacts, may be considered.[76]
go to our full topic on Addison disease
Patients with adrenal insufficiency are at an increased risk of infection, which may be complicated by developing an adrenal crisis. Guidance on prevention of adrenal crisis in patients with confirmed or suspected COVID-19 is available.[79] Patients should be given support to help them self-manage their condition safely and should be educated in the use of sick day rules. The guidelines recommend that patients with symptoms of COVID-19 should seek medical advice, and should take oral hydrocortisone or prednisone as directed. Patients are also advised to take acetaminophen for fever, and to drink regularly, monitoring how concentrated their urine appears. If there are signs of clinical deterioration (such as dizziness, intense thirst, shaking uncontrollably, drowsiness, confusion, lethargy, vomiting, severe diarrhea, increasing shortness of breath, respiratory rate >24/min, difficulty speaking) the patient or carer should inject hydrocortisone intramuscularly and call for emergency medical assistance.[79] Hospitalized patients should receive intravenous hydrocortisone and continuous intravenous fluid resuscitation with isotonic saline; fludrocortisone should be temporarily stopped.
go to our full topic on Aplastic anemia
The definitive treatment options for severe aplastic anemia (AA) are stem cell transplant or immunosuppressive therapy. The American Society of Hematology advise that for patients with absolute neutrophil count (ANC) <200/microlitre (very severe AA) the risk of delaying transplant or immunosuppressive therapy outweighs the risks of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during hospitalization or the impact of immunosuppression on the course of infection, but that optimal management may not currently be practical.[80]
Immunosuppressive treatment options are antithymocyte globulin (ATG), cyclosporine, and eltrombopag; administration of ATG requires hospitalization. The American Society of Hematology, the European Society for Blood and Marrow Transplantation, and NHS England have released statements recommending the use of eltrombopag, with or without cyclosporine, as bridging treatment to stem cell transplant or immunosuppressive therapy with ATG for patients with severe or very severe AA during the COVID-19 pandemic.[80][81][82]
Trials of SARS-CoV-2 vaccination in patients with hematologic conditions are lacking. Such patients are likely to have an attenuated response to vaccination. One small study reported a reduced seroconversion rate and lower antibody response after a first dose of SARS-CoV-2 vaccine in people with aplastic anemia, compared with healthy controls. After a second vaccination, seropositivity and antibody levels were equivalent in people with aplastic anemia, and healthy controls.[83]
Measures, such as early vaccination of household contacts, may be considered.[76] The American Society of Hematology advises that the benefits of COVID-19 vaccination outweigh the risks in patients with AA, particularly those with additional risk factors for severe COVID-19 disease, though some patients receiving immunosuppressive therapies may not mount an appropriate immune response to the vaccine.[80]
go to our full topic on Asthma
Patients should continue taking their prescribed asthma medication as usual, including inhaled and oral corticosteroids and biologic therapy.[84][85][86][87] GINA advises that all patients should have a written action plan so they know how to recognize worsening asthma, how to increase reliever and controller medications, and when to seek medical help.[85] GINA advises that nebulizers should be avoided for acute attacks due to the risk of transmitting respiratory viral particles, and that a pressurized metered-dose inhaler and spacer with mouthpiece or tightly fitting facemask can be used to deliver a short-acting beta-2 agonist instead.[85] The US Centers for Disease Control and Prevention advises that nebulizer administration may generate infectious aerosols; however, it is unclear whether association between nebulizer administration and infection is due to the generation of infectious particles or the close contact between the patient and healthcare professional administering the nebulizer.[88] GINA advises that local COVID-19 testing recommendations and infection control procedures are followed if spirometry and peak-flow measurement is needed.[85] GINA advises that use of an in-line filter can minimize risk of transmission during spirometry and that patients should be advised to stay on the mouthpiece if they feel the need to cough.[85] The American Academy of Allergy, Asthma & Immunology (AAAAI) has provided recommendations on the safe practice of pulmonary procedures, including spirometry, fractional exhaled nitric oxide, nebulized treatments, and methacholine challenge.[89]
Patients should ensure they have a sufficient supply of medication at home, but should not stockpile. Patients may be reminded that they should not share inhalers or spacers with others. Clinicians should encourage smoking cessation.[84]
GINA recommends COVID-19 vaccination for people with asthma, following the usual vaccine precautions.[85] For people with severe asthma receiving biologic therapy, the COVID-19 vaccine and the biologic therapy should not be given on the same day.[85]
go to our full topic on Autoimmune hepatitis
A cohort study of 500,000 people in the UK found that autoimmune disease and history of oral corticosteroid were associated with increased risk of fatal COVID-19.[90] UK, European, and US guidelines advise against making anticipatory adjustments to immunosuppressive drugs in patients without COVID-19.[91][92] Doing so may cause a flare of autoimmune hepatitis (AIH). Budesonide may be considered to induce remission in patients without cirrhosis who have a flare of AIH, to minimize systemic corticosteroid exposure.[92]
The American Association for the Study of Liver Disease (AASLD) advises that immunosuppressive therapy should be commenced in patients with AIH, with or without COVID-19.[91]
If a patient develops COVID-19, the AASLD advises that clinicians consider reducing doses of immunosuppressants, particularly azathioprine and mycophenolate, based on general principles for managing infections in immunosuppressed patients and to decrease the risk of superinfection.[91] Adjustment should be individualized and will depend on the severity of COVID-19. If a patient is taking corticosteroids and develops COVID-19, corticosteroid dosing must be sufficient to prevent adrenal insufficiency.[92]
COVID-19 may cause abnormal liver function tests in patients with AIH; these should not be attributed to a disease flare without biopsy confirmation.[91]
A joint statement from the British Society of Gastroenterology, British Association for the Study of the Liver, NHS Blood & Transplant, and British Liver Trust advises that patients with autoimmune hepatitis should consider SARS-CoV-2 vaccination with any of the available vaccines.[93]
go to our full topic on Breast cancer
COVID-19 vaccination is associated with a higher incidence of axillary lymphadenopathy on breast MRI and mammography.[94][95] One study reported the incidence of mammographic axillary lymphadenopathy following COVID-19 vaccination as 3%.[95] Guidelines have been published to help avoid biopsies of reactive nodes. MRI-detected, unilateral, axillary lymphadenopathy ipsilateral to the vaccination arm is most likely to be COVID-19 vaccination-related if within 4 weeks of either dose. A follow-up ultrasound 6 to 8 weeks after the second vaccine dose is recommended.[94]
go to our full topic on Bronchiolitis
UK guidance recommends optimizing preventive treatment, including influenza vaccination and palivizumab for eligible children.[96] Key features of assessment are oxygenation, hydration, and nutrition, irrespective of the child’s potential COVID-19 status. High-flow nasal cannula oxygen is an aerosol-generating procedure; a senior clinician should be consulted if its use is being considered. Children who require admission to hospital should be tested for respiratory viruses, including severe acute respiratory syndrome coronavirus (SARS-Cov-2), influenza, and respiratory syncytial virus. Children who require intensive/high-dependency care or surgery should be prioritized for rapid SARS-CoV-2 testing.
go to our full topic on Cardiopulmonary resuscitation (CPR)
Giving CPR poses a high risk to healthcare workers in the context of COVID-19 due to the aerosol-generating procedures, close proximity of multiple healthcare workers and the patient, and the need to work quickly.
If cardiac arrest is recognized (patient is unresponsive and breathing abnormally), UK and international (ILCOR) guidelines advise looking for breathing, but advise against opening the airway or listening/feeling for breathing by placing the face close to the patient's mouth.[97][98]
In acute hospital settings, UK guidelines advise that full Aerosol Generating Procedure (AGP) Personal Protective Equipment (PPE) must be worn by all members of the resuscitation team before entering the room; no chest compressions or airway procedures should be started without full AGP PPE. The number of staff in the room should be restricted, and airway interventions should be done by experienced staff, minimizing aerosolization risk.[98] Updated US guidelines now advise that chest compressions or defibrillation should not be delayed for provider PPE, but that initial resuscitation personnel should be relieved by providers wearing appropriate PPE as soon as possible.[99] If the patient cannot be placed supine, cardiopulmonary resuscitation may be provided in the prone position, particularly if the patient has advanced airway and circulatory support.[100]
In first aid and community settings, lay-rescuers should perform compression-only resuscitation and defibrillation (where there is access); a cloth may be placed over the patient's mouth and nose if there is a perceived risk of infection. Pediatric cardiac arrest is more likely to be caused by a respiratory problem, and ventilation is vital; lay-rescuers may consider that the risk of not giving rescue breaths could be greater than the risk of transmission of COVID-19.[97][98][99]
In-water mouth-to-mouth resuscitation should not be performed on drowned patients. Rescuers should prioritize removal from water where PPE and first aid equipment can be used. Rescuers should wear gloves, facemask and eye protection for all resuscitations. Two-person bag-filter-mask ventilation using a high-efficiency particulate arrestance (HEPA) filter is preferred. If this is not possible, mouth-to-mask ventilation with HEPA filter is the second line technique and passive oxygenation is third line. If rescuers cannot follow this guidance, they should provide compression only CPR and cover the patient’s nose and mouth with a cloth.[101]
Brazilian guidelines recommend beginning continuous chest compressions to deliver CPR to adults. The patient’s oral cavity should be sealed with a cloth or a mask providing low flow (6-10 liters/minute) oxygen before starting chest compressions; the seal should be kept in place until an invasive airway is secured. Bag-valve-mask or bag-valve tube ventilation should be avoided if possible; if it is needed, two rescuers should provide ventilation (to allow a two-handed seal around the mask) and an oropharyngeal airway should be used. A HEPA filter should be placed between the mask and bag. If the patient is prone at the time of cardiac arrest and does not have an invasive airway, they should be repositioned supine. If the patient is intubated, chest compressions should be delivered while prone. Resuscitation of children should ideally be with chest compressions and use of a bag-valve-mask apparatus with a HEPA filter until a definitive airway is established.[102]
go to our full topic on Chronic kidney disease
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) BNT162b2 mRNA vaccine induces comparable neutralizing antibody titers in patients receiving hemodialysis and healthy controls. The adenovirus-associated vector vaccine ADZ1222 induced suboptimal neutralizing antibodies in seronaive patients receiving hemodialysis.[103] A retrospective observational study in the US found that, among patients receiving hemodialysis, vaccination with BNT162b2 or mRNA-1273 was associated with a lower risk of COVID-19 diagnosis and a lower risk of hospitalization or death among those diagnosed with COVID-19.[104] Another retrospective cohort study in the US found that among patients receiving maintenance dialysis, vaccine-induced seroresponse wanes over time across vaccine types.[105]
go to our full topic on Chronic lymphocytic leukemia
There are limited data on trials of severe acute respiratory syndrome coronavirus 2 vaccination in patients with hematological conditions. Such patients are likely to have an attenuated response to vaccination. Studies of the BNT162b2 mRNA COVID-19 vaccine in patients with CLL found the antibody response was reduced compared with healthy controls and affected by disease activity and treatment.[75][106] Relatively low antibody responses were seen in patients treated with Bruton's tyrosine kinase inhibitors or venetoclax alone or in combination with antiCD20 antibody. Additional measures, such as early vaccination of household contacts, may be considered.[76]
go to our full topic on Chronic myelogenous leukemia
Possible drug-drug interactions should be reviewed in patients being treated for COVID-19.
There are limited data on trials of severe acute respiratory syndrome coronavirus 2 vaccination in patients with hematological conditions. Such patients are likely to have an attenuated response to vaccination. One study of the BNT162b2 mRNA COVID-19 vaccine in patients with hematological malignancies found the antibody response was reduced compared with healthy controls, and was affected by disease treatment.[75] Additional measures, such as early vaccination of household contacts, may be considered.[76]
Chronic obstructive pulmonary disease (COPD)
Signs & symptoms
Investigations
Differentials
Treatment algorithm
go to our full topic on Chronic obstructive pulmonary disease (COPD)
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends that patients with COPD who have new or worsening respiratory symptoms, fever, and/or any other possible COVID-19-related symptoms should be tested for severe acute respiratory disease coronavirus 2 (SARS-CoV-2), even if the symptoms are mild.[107] A large prospective cohort study found that patients aged 50 years and older with COPD, with or without asthma, were more likely to require supplemental oxygen and noninvasive ventilation, but less likely to receive invasive mechanical ventilation or critical care compared with patients without a respiratory condition. Mortality in this group exceeded 40%.[108]
GOLD advises that patients should maintain their regular treatment and that there is currently no evidence to recommend avoiding corticosteroids (inhaled or oral) in patients with COPD during the COVID-19 pandemic.[107]
Exacerbations of COPD should be managed by the patient following their individualized plan, and there should be no change to advance prescribing of rescue antibiotics and corticosteroids. Patients should not start rescue antibiotics and corticosteroids to treat symptoms of COVID-19, and should not start prophylactic antibiotics to reduce risk.[109] Canadian guidelines recommend that patients with COPD who develop COVID-19 should continue their usual inhaled maintenance therapy and that acute exacerbations of COPD should be treated with prednisone if needed, irrespective of whether the exacerbation is triggered by SARS-CoV-2.[86]
To reduce the risk of acute exacerbations, and a poorer outcome from COVID-19 infection, strongly encourage patients who are still smoking to stop.[109]
GOLD considers nebulization to have an increased risk of droplet generation and disease transmission.[107] GOLD advises that where possible, dry powder inhalers, pressurized metered dose inhalers, and soft mist inhalers are used instead of nebulizers for drug delivery. The US Centers for Disease Control and Prevention advises that nebulizer administration may generate infectious aerosols, however it is unclear whether association between nebulizer administration and infection is due to the generation of infectious particles or the close contact between the patient and healthcare professional administering the nebulizer.[88]
GOLD recommends that during periods of high COVID-19 prevalence, spirometry is restricted to patients requiring urgent diagnosis of COPD, and/or to assess lung function prior to interventional procedures or surgery.[107]
The British Thoracic Society has developed online pulmonary rehabilitation resources for patients to use while face-to-face meetings are not possible and a resource pack for patients who survive COVID-19.[110]
One study in Singapore reported a significant and sustained decrease in hospital admissions for acute exacerbations of COPD, including respiratory virus infection-associated acute exacerbations, during the pandemic, which coincided with the introduction of public health measures such as social distancing and universal mask-wearing.[111]
go to our full topic on Cirrhosis
Patients with chronic liver disease have a higher mortality rate from COVID-19 infection, and mortality is associated with liver disease severity.[91][92] COVID-19 infection may precipitate acute-on-chronic liver failure in patients with decompensated cirrhosis.[112]
European guidelines advise that patients who have cirrhosis and COVID-19 should be admitted to the hospital for inpatient care. Such patients are at high risk of new or worsening hepatic decompensation, severe COVID-19, and death.[92] Patients with cirrhosis and portal hypertension should avoid nonsteroidal anti-inflammatory drugs. Care should be taken to avoid acetaminophen overdosing in patients with cirrhosis.[113]
Patients with cirrhosis may have an attenuated response to SARS-CoV-2 vaccination; however, experts recommend priority vaccination for these patients because of the high COVID-19-related mortality in patients with decompensated cirrhosis.[114] A joint statement from the British Society of Gastroenterology, British Association for the Study of the Liver, NHS Blood & Transplant, and British Liver Trust advises that patients with chronic liver disease should consider SARS-CoV-2 vaccination with any of the available vaccines.[93] One cohort study of individuals with cirrhosis found that use of COVID-19 mRNA vaccines were associated with a reduction in COVID-19 infection and a reduction in hospitalization or death due to COVID-19 infection after 28 days.[115]
Clostridium difficile-associated disease
Signs & symptoms
Investigations
Differentials
Treatment algorithm
go to our full topic on Clostridium difficile-associated disease
As there is a potential risk of transmission of severe acute respiratory disease coronavirus 2 (SARS-CoV-2) via fecal microbiota transplantation (FMT), the US Food and Drug Administration (FDA) has made the following new recommendations for stool donated after 1 December 2019:[116]
- Screen donors to identify those who may be currently or recently infected with SARS-CoV-2.
- Test donors and/or donor stool for SARS-CoV-2, if possible.
- Patients should give informed consent after being advised about the potential risk of transmission of SARS-CoV-2 via FMT.
Stool used for FMT should have been donated before 1 December 2019 if these criteria are not met.
go to our full topic on Community-acquired pneumonia
Antibiotics should be started as soon as possible for patients in the community with suspected or confirmed secondary bacterial pneumonia. Patients should be advised to seek urgent medical help if their symptoms do not improve as expected, or rapidly or significantly worsen, regardless of whether they are taking an antibiotic. Antibiotics should not be used to prevent secondary bacterial pneumonia.[66]
Tests including respiratory and blood cultures, severe acute respiratory disease coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR), throat samples for respiratory viral and atypical pathogen PCR, chest imaging, full blood count, and urinary legionella and pneumococcal antigen tests are recommended for patients admitted to hospital (or other acute care settings), to help identify secondary bacterial pneumonia and guide decisions about antibiotic use.[66] High C-reactive protein (CRP) levels do not distinguish between bacterial and COVID-19 pneumonia, but low CRP levels make secondary bacterial pneumonia less likely.[66]
Empiric antibiotics should be started if there is clinical suspicion of secondary bacterial infection in patients with COVID-19 in hospital.[66] Antibiotic treatment should be started within 4 hours of diagnosis and within 1 hour if the patient has suspected sepsis.[66] Choice of antibiotic will depend on local resistance data and availability. Specialist advice on antibiotic choice is recommended for patients who are immunocompromised, pregnant, in critical care, or who have a history of infection with resistant organisms or repeated infective exacerbations of lung disease.
Use of antibiotics should be reviewed at 24-48 hours, or as soon as test results are available. A narrower spectrum antibiotic should be used, if appropriate. Antibiotic treatment should stop after five days, unless there is an indication to continue.[66] Patients should be reassessed if they do not improve as expected, or if symptoms become significantly or rapidly worse. Specialist advice should be sought if there is clinical or microbiological evidence of infection and the person’s condition does not improve after 48-72 hours antibiotic treatment, or if an infection with multidrug-resistant bacteria is suspected.[66]
Where possible, clinicians should discuss the benefits, risks, and likely outcomes of any treatment with the patients, their relatives, and caregivers. The patient's preference about treatment and escalation plans should be sought, and clinicians should enquire about any advance care plans, advance decisions to refuse treatment, or "do not attempt resuscitation" decisions.[66]
World Health Organization guidelines advise that antibiotics should not be prescribed for patients with mild COVID-19 and should only be prescribed for patients moderate COVID-19 if there is clinical suspicion of a bacterial infection.[57]
Fever, cough, and shortness of breath may be symptoms of fungal pneumonias, including coccidioidomycosis, histoplasmosis, and blastomycosis. Fungal pneumonias may be indistinguishable from COVID-19 and bacterial pneumonias. The diagnosis should be considered if SARS-CoV-2 testing is negative, although coinfection with fungi and SARS-CoV-2 may occur.[117]
go to our full topic on Congenital heart disease
People with congenital heart disease (CHD) may be at increased risk for more severe COVID-19 infection, particularly those with more severe anatomic and physiologic features of CHD.[118][119] Simple biventricular defects, complex ventricular defects, and heart surgery are associated with severe COVID-19.[120] Additional considerations for management have been recommended during the current pandemic with strategies for prevention and management of COVID-19 in adults with CHD based on risk stratification.[119][121] For example, patients in the low risk category (e.g., those with normal ventricular function, normal exercise capacity, no relevant arrhythmia, no pulmonary hypertension) can be advised to take general prevention measures against COVID-19. Low risk patients with mild COVID-19 infection may be cared for at home with remote follow-up, but there should still be a low threshold for hospital admission if there is deterioration/progression or dyspnea. Adults with CHD in the high risk category (e.g., those with cyanotic conditions, univentricular palliated conditions, severe stenosis or regurgitation, severe ventricular dysfunction, or pulmonary arterial hypertension) are advised to follow stricter prevention measures, such as physical distancing. High risk patients with COVID-19 infection generally require hospital admission and involvement of a CHD specialist.
It is recommended that cardiac medications, including aspirin, ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers, diuretics, and antiarrhythmic medications are continued during COVID-19 illness, unless there is a clear contraindication.[118]
In the UK, people aged 12 years or above with specific underlying health conditions that put them at risk of severe COVID-19 should be offered vaccination; this currently includes those with congenital heart disease.[28]
go to our full topic on Crohn disease
International guidelines recommend that patients should stop taking methotrexate, thiopurines, or tofacitinib if they develop COVID-19. Detailed recommendations for stopping and restarting medications are given depending on the level of inflammatory bowel disease activity and severity of COVID-19 infection.[122][123] Decisions on surgery should be individualized for each patient with a multidisciplinary team.[124]
The British Society of Gastroenterology has published a position statement strongly supporting SARS-CoV-2 vaccination for patients with IBD.[125] A third dose (or booster dose) of SARS-CoV-2 vaccine is also recommended for all patients with IBD receiving immunosuppressive treatment and all patients with IBD who are extremely clinically vulnerable. A third dose of SARS-CoV-2 vaccine results in a serologic response in 84% of patients with immune-mediated inflammatory diseases who had a weak response to the standard 2-dose regimen.[126] Some immunosuppressive therapies may impact efficacy of COVID-19 vaccines in patients with IBD, and this should be considered in the timing of vaccinations.[126][127]
Prognostic models for predicting the probability of adverse COVID-19 outcomes in patients with IBD are being developed.[128]
go to our full topic on Cushing syndrome
Management of Cushing syndrome is complex and recommendations for clinical practice during the COVID-19 pandemic have been developed by an international group of experts.[129] They advise that patients with active Cushing syndrome are immunosuppressed, and should follow public health advice to minimize their risk of infection.[129] Patients with active Cushing syndrome who develop COVID-19 may not develop fever, and symptoms of dyspnea may be more severe.[130] Cushing syndrome is a hypercoagulable state and anticoagulation with low molecular weight heparin is recommended for hospitalized patients with COVID-19 and Cushing syndrome.[130] Patients with active Cushing syndrome are at risk of prolonged viral infection and secondary bacterial and fungal infection. Prolonged antiviral treatment and empirical antibiotic prophylaxis should be considered for hospitalized patients.[130]
Patients with severe Cushing syndrome should receive prophylaxis for Pneumocystis jirovecii; symptoms of COVID-19 may be similar to infections such asPneumocystis jirovecii pneumonia, and differentiation is needed to ensure appropriate treatment.[129]
go to our full topic on Diabetes (type 1)
COVID-19 disease can precipitate atypical presentations of diabetes emergencies (e.g., mixed diabetic ketoacidosis and hyperosmolar states).[131] At admission hyperglycemia may also be an independent factor associated with poor prognosis for those hospitalized with COVID-19.[132][133]
UK guidance advises checking blood glucose and ketones in all patients with diabetes who are admitted to the hospital.[131] Out of the hospital, patients should follow their usual sick day rules, taking care to continue insulin, remain hydrated, and monitor blood glucose and ketones as appropriate.[134][135] Clinicians may need to prescribe additional blood glucose and ketone testing equipment to support increased monitoring. Patients admitted to intensive care may have insulin resistance and increased insulin requirements. There is a risk of hypoglycemia if feeding is interrupted (e.g., if the patient is nursed prone).[131] Specialist advice may be needed, particularly for patients who have severe illness on admission or if infusion pumps for insulin are not available.[131]
go to our full topic on Diabetes (type 2)
In the UK, people aged 12 years or above with specific underlying health conditions that put them at risk of severe COVID-19 should be offered vaccination; this currently includes those with type 2 diabetes.[28]
go to our full topic on Giant cell arteritis
A cohort study of 500,000 people in the UK found that autoimmune disease and history of oral corticosteroid were associated with increased risk of fatal COVID-19.[90] Experts recommend that patients taking long-term glucocorticoids for giant cell arteritis (GCA) should titrate the dose down to the lowest possible dose that achieves symptom control. Patients at risk of adrenal insufficiency who develop COVID-19 may require additional doses of glucocorticoid to prevent an adrenal crisis. Adjuvant immunosuppression should be considered at an early stage, since major relapse of GCA might require in-person consultation and/or significant glucocorticoid dose increases.[136]
Clinicians are advised to engage patients with rheumatic disease in a shared decision-making process to discuss receiving a severe acute respiratory disease coronavirus 2 (SARS-CoV-2) vaccine. The response to vaccination is likely to be blunted in patients receiving systemic immunomodulatory therapies compared with the general population. The American College of Rheumatology advises that, beyond known allergies to vaccine components, there are no additional contraindications to SARS-CoV-2 vaccination for patients with autoimmune and inflammatory rheumatic diseases. Vaccination should ideally occur when rheumatologic disease is well controlled.[137] EULAR recommends that patients with rheumatic and musculoskeletal diseases are strongly advised to receive a SARS-CoV-2 vaccination with any of the vaccines approved in their country.[138]
go to our full topic on Hepatitis B
Usual treatment should be continued for patients with chronic hepatitis B (HBV) infection who are established on treatment. In patients without COVID-19, treatment should be initiated according to local or national guidelines.[92] The impact of interferon alfa on systemic inflammation in patients with COVID-19 is not known. European Association for the Study of the Liver (EASL) guidelines recommend that alternative agents should be considered when starting treatment for HBV during the pandemic.[92]
Patients who have chronic, occult, or resolved HBV infection and COVID-19 should be considered for antiviral therapy to avoid HBV reactivation and hepatitis flare if they receive immunosuppressive agents for treatment of COVID-19.[92][139] EASL guidelines advise that initiation of antiviral therapy is usually not warranted in patients with HBV and COVID-19 and may be deferred until recovery. In patients with suspected severe acute HBV hepatitis or a flare of disease activity, a specialist should be consulted to decide whether to initiate antiviral therapy.[92] Asia-Pacific guidelines recommend that patients who are newly diagnosed with HBV infection at the time of presentation with COVID-19 should be started on antiviral therapy.[139]
In the UK, people aged 16 years or above with specific underlying health conditions that put them at risk of severe COVID-19 should be offered vaccination; this currently includes those with chronic hepatitis.[28]
go to our full topic on HIV infection
Influenza and pneumococcal vaccinations should be kept up to date.[140][141] Antiretroviral therapy should be continued in the hospital without interruption. Changes in antiretroviral therapy are generally not recommended. Pre-exposure prophylaxis to prevent HIV infection should be taken as directed; there is no evidence that it is effective against COVID-19.[142] The Centers for Disease Control and Prevention recommends that people with HIV can receive the Pfizer-BioNTech and Moderna vaccines if they have no contraindications. It is not yet known whether the level of protection is as strong for people with HIV as people without HIV.[143] One prospective cohort study of CoronaVac found that immunogenicity in people with HIV was reduced compared with people with no known immunosuppression.[144]
Further resources are available at:
WHO: Q&A - HIV, antiretrovirals and COVID-19 Opens in new window
Guidance for COVID-19 and people with HIV Opens in new window
HIVinfo: HIV and opportunistic infections, coinfections, and conditions Opens in new window
go to our full topic on Idiopathic pulmonary fibrosis
Patients with idiopathic pulmonary fibrosis are at increased risk of hospitalization and death due to COVID-19.[145] The Canadian Thoracic Society has published guidelines for the management of patients with interstitial lung disease, including idiopathic pulmonary fibrosis, during the pandemic.[146]
Decisions about stopping, adjusting, and restarting treatment in patients who develop COVID-19 should be made in conjunction with the patient's specialist team.[146]
Initiation of immunotherapy should be deferred in patients with newly diagnosed or suspected COVID-19.[146] Clinicians should use the lowest effective dose of immunotherapy in patients without COVID-19.[146] Antifibrotic drugs may be continued if the patient's blood parameters are in the acceptable range and there is no other reason to stop (e.g., significant adverse effects).[146]
Antifibrotic therapy does not increase the risk of getting COVID-19 or make severe disease more likely. Patients who are already taking antifibrotic therapy should continue. Patients with a new diagnosis of idiopathic pulmonary fibrosis may start antifibrotic therapy if a multidisciplinary team confirms the diagnosis, usual eligibility criteria are satisfied, and the appropriate blood monitoring can be performed.[146]
Clinical judgment is needed to determine the urgency of diagnostic and therapeutic bronchoscopy. Elective bronchoscopy or lung biopsy should be deferred in patients with SARS-CoV-2 infection.[146]
Patients with persistent respiratory symptoms following recovery from COVID-19 should be evaluated for post-COVID pulmonary fibrosis and/or exacerbation of pre-existing interstitial lung disease.[146]
Further resources are available at:
British Thoracic Society. COVID-19: information for the respiratory community. Opens in new window
go to our full topic on Immune thrombocytopenia
The American Society for Hematology has published advice on management of immune thrombocytopenia (immune thrombocytopenic purpura [ITP]) during the pandemic. Hospital visits should be minimized and treatment guided by symptom management rather than frequent platelet counts. Viral infections can trigger acute ITP or trigger exacerbations in patients with stable disease, so testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is recommended in these patients.[147]
Treatment of new patients should be individualized depending on: urgency of need to increase the platelet count, amount of bleeding, comorbidities, minimizing exposure to SARS-CoV-2, and usual practice. Most patients with immune thrombocytopenia do not experience severe bleeding with platelet counts above 20,000/microliter, in the absence of comorbidities. Intravenous immune globulin (IVIG) or oral thrombopoietic agents (e.g., eltrombopag or avatrombopag) are first line because they are not immunosuppressive. No change to treatment is recommended for patients who are stable on low doses of immunosuppressive drugs. Treatment change may be considered for patients taking higher doses of immunosuppressive drugs or corticosteroids; however, this must be balanced against the increased monitoring requirements and risk of relapse. If indicated, IVIG or oral thrombopoietic agents may allow dose reduction or cessation of immunosuppressive medication or corticosteroids. Rituximab should be avoided if possible.[147]
If a patient with immune thrombocytopenia develops COVID-19, IVIG should be given to maintain the platelet count above 10,000-20,000/microliter; platelet transfusion should be reserved to treat bleeding or cover procedures with a high bleeding risk. If the patient already takes a thrombopoietic agent, the dose can be increased or a second agent may be started. Treatments for COVID-19 illness should be given as appropriate. If the patient has had a splenectomy, intravenous antibiotics should be administered until bacterial cultures are documented negative, even if COVID-19 is strongly suspected as the cause.[147]
The guidance advises that vaccine administration in general can occasionally result in a drop in the platelet count in stable ITP patients; however, current knowledge suggests that the expected benefits of receiving the SARS-CoV-2 vaccine likely outweigh the risks.[147] Taking baseline and postvaccination platelet counts may be considered, particularly in those with ongoing thrombocytopenia or a history of unstable platelet counts.
go to our full topic on Influenza
Signs and symptoms of influenza infection and COVID-19 infection are similar and can be difficult to distinguish clinically; only testing can distinguish between them. The US National Institutes of Health (NIH) COVID-19 Treatment Guidelines recommend testing for both SARS-CoV-2 and influenza viruses in all hospitalized patients with acute respiratory illness when both viruses are co-circulating.[148] The guidelines advise that treatment of influenza is the same in all patients, regardless of SARS-CoV-2 coinfection, and that hospitalized patients should be started on empiric treatment for influenza as soon as possible without waiting for influenza testing results (antiviral treatment for influenza can be stopped when influenza has been ruled out by nucleic acid detection assay in upper respiratory tract specimens for nonintubated patients, and in both upper and lower respiratory tract specimens for intubated patients).[148]
go to our full topic on Liver dysfunction
Patients with COVID-19 may have abnormal liver function tests, including elevated aminotransferases and mildly elevated bilirubin. Low serum albumin on admission to the hospital is a marker of COVID-19 severity. Recommendations from the American Association for Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA), and the Asia-Pacific Working Group for Liver Derangement during the COVID-19 Pandemic all advise regular monitoring of liver biochemistries in all hospitalized patients with COVID-19, particularly those treated with remdesivir or tocilizumab, regardless of baseline values.[91][139][149] The Asia-Pacific Working Group advises that while the optimal interval for liver tests is uncertain, it would be reasonable to monitor liver tests twice weekly in patients on potentially hepatotoxic medication and patients with pre-existing liver disease, and more frequently in any patients with abnormal liver function.[139] The AASLD also advises that abnormal liver biochemistries should not be a contraindication to using investigational or off-label therapeutics for COVID-19, although aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels >5 times the upper limit of normal (ULN) may exclude patients from consideration of some investigational agents.[91] The Asia-Pacific Working Group recommends that off-label COVID-19 therapies may be used with caution and close monitoring in those with abnormal liver function; the treatment should be stopped in those with moderate-to-severe liver injury (ie, ALT >5 times ULN or alkaline phosphatase >2 times ULN, and total bilirubin >2 times ULN or presence of coagulopathy or clinical decompensation).[139] Other causes of abnormal liver function tests, including viral hepatitides, should be considered in patients with COVID-19 and abnormal liver biochemistries.[139][149] In patients with autoimmune hepatitis or liver transplant recipients who develop COVID-19, suspected disease flare or acute cellular rejection should be confirmed on biopsy.[91] The Asia-Pacific Working Group recommends screening for hepatitis B surface antigen (HBsAg) in patients who are receiving systemic corticosteroids or other potent immunosuppressants for 7 days or longer as COVID-19 therapy. Tocilizumab has been associated with HBV reactivation. European guidelines recommend screening with HBV serology before initiating treatment with tocilizumab.[92]
A joint statement from the British Society of Gastroenterology, British Association for the Study of the Liver, NHS Blood & Transplant, and British Liver Trust advises that patients with chronic liver disease, autoimmune hepatitis, and those post-liver transplant should consider SARS-CoV-2 vaccination with any of the available vaccines.[93]
go to our full topic on Mucormycosis
Mucormycosis has been increasingly reported in patients with coronavirus disease 2019 (COVID-19), particularly in patients who have diabetes and have also received corticosteroids.[150][151][152][153][154][155] Clinicians should have a low threshold of suspicion for diagnosis. Warning signs and symptoms include: nasal congestion; blackish/bloody nasal discharge; sinus or facial pain; toothache or loosening of teeth; vision disturbances; hemoptysis; and necrotic eschar on skin, palate, or nasal turbinates. Management strategies in the context of COVID-19 include, but are not limited to: controlling hyperglycemia, diabetes, or diabetic ketoacidosis; reducing corticosteroid dose with the aim to rapidly discontinue; discontinuing immunomodulating drugs; extensive surgical debridement to remove all necrotic material; antifungal therapy (e.g., amphotericin-B) for 4 to 6 weeks; and appropriate supportive care and monitoring.[156][155] Prevention involves: controlling hyperglycemia; monitoring blood glucose level in COVID-19 patients after discharge (whether or not they are diabetic); and judicious use of corticosteroids, antibiotics, and antifungals.[156]
go to our full topic on Multiple myeloma
There are limited data on trials of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination in patients with hematological conditions. However, available data in patients with multiple myeloma suggest an attenuated response to vaccination.[157] The European Myeloma Network has published a consensus for vaccination against SARS-CoV-2, recommending that all patients with monoclonal gammopathy of unknown significance, smouldering multiple myeloma, multiple myeloma, and monoclonal gammopathies of clinical significance are vaccinated with a COVID vaccine.[158] Recommendations are also given on when patients should preferably be vaccinated, the risk factors that should be considered for a poor response to vaccination, and actions that can be considered in the case of immune impairment.[158]
go to our full topic on Multiple sclerosis
The Association of British Neurologists (ABN) has produced guidance on the use of disease-modifying therapies in patients with multiple sclerosis (MS) during the pandemic.[159] The ABN advises that the effect of disease-modifying therapies on the risk of COVID-19 remains uncertain. Disease-modifying treatments should be offered to patients, provided that the benefits of treatment outweigh the risks. The local rate of COVID-19 infection, the patient’s general health, and their exposure to the virus all influence this risk/benefit decision. Patients should be advised if their disease-modifying therapy might affect the efficacy of a vaccine or the severity of COVID-19. The guidance provides information on considered level of risk for specific disease-modifying therapies.[159] The US National MS Society also recommends that decisions on the use of disease-modifying therapies are individualized and should consider disease factors, risks and benefits of therapies, and risks associated with COVID-19.[160] The National MS Society recommends that people currently taking disease-modifying therapies should continue, and if they develop symptoms of COVID-19 or test positive, their therapies should be reviewed with someone familiar with their care.
Observational studies of patients with MS have found that risk factors for severe forms of COVID-19 are older age, increased levels of disability (Expanded Disability Severity Scale [EDSS] score ≥6, requiring assistance to walk, or being unable to walk), black race, cardiovascular disease, diabetes, obesity, and corticosteroid treatment within the previous 2 months.[161][162] One study found no association between use of disease-modifying therapies and severity of COVID-19.[161] Another study found that patients taking rituximab had an increased risk of hospitalization compared with patients who did not take any disease-modifying therapy, but there was no significantly increased risk of intensive care unit admission, need for mechanical ventilation, or death among the patients taking rituximab.[162]
Some disease-modifying therapies may impact efficacy of COVID-19 vaccines, and this should be considered in the timing of treatment courses and vaccinations.[163][164][165][166][167] Effective cytotoxic T-cell responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported in patients with MS who were treated with ocrelizumab and received two or three doses of SARS-CoV-2 vaccine.[168]
go to our full topic on Non-Hodgkin lymphoma
Analysis of US health-insurance claims data has shown that lymphoma is a significant risk factor for fatal COVID-19.[72] Indolent and aggressive non-Hodgkin lymphomas are associated with worse survival in patients with COVID-19.[169][77] Interim treatment guidelines for the management of adult patients during the pandemic have been provided by experts from the UK and also from Australia and New Zealand.[170][171] For most patients with aggressive non-Hodgkin lymphoma subtypes, treatment is delivered with curative intent and this remains the clinical priority. Recommendations are given for patients with Burkitt lymphoma, diffuse large B-cell lymphoma (DLBCL), primary mediastinal B cell lymphoma, central nervous system (CNS) lymphoma, peripheral T cell lymphoma, and relapsed/refractory aggressive lymphoma. For patients with low-grade non-Hodgkin lymphoma and not requiring immediate treatment, watchful waiting may be considered; initiation of treatment should be based on a risk–benefit discussion between the patient and physician.
The American Society for Hematology has published advice for the management of aggressive lymphomas. R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) remains the standard of care for diffuse large B cell lymphoma. For older patients, R-mini-CHOP (a reduced dose regimen) with growth factor support is recommended. Subcutaneous rituximab may be considered for patients who have tolerated a first intravenous dose. Recommendations are also given for double-hit and primary mediastinal B cell lymphomas, patients at higher risk of CNS involvement, and patients with relapsed or refractory disease.[172] The International Lymphoma Radiation Oncology Group has published emergency guidelines for radiation therapy in hematologic malignancies, should radiation therapy be necessary. Alternative dose fractionations may be given.[173]
There are limited data on trials of severe acute respiratory syndrome coronavirus 2 vaccination in patients with hematological conditions. Such patients are likely to have an attenuated response to vaccination. One study of the BNT162b2 mRNA COVID-19 vaccine in patients with hematological malignancies found the antibody response was reduced compared with healthy controls, and was affected by disease treatment.[75] Additional measures, such as early vaccination of household contacts, may be considered.[76]
go to our full topic on Obesity in adults
Obesity (body mass index [BMI] ≥30kg/m²) is associated with increased risk of a positive COVID-19 test, hospitalization, severe COVID-19 requiring admission to intensive care, mechanical ventilation, and death.[174][175][176][177][178][179][180][181][182][183] The association is strongest in patients <65 years.[175][180] One meta-analysis found that obesity was associated with a 12% increase in absolute risk of COVID-19 death.[184] Patients with obesity who develop COVID-19 are also at higher risk for venous thromboembolism and dialysis.[178]
Being overweight (BMI >25kg/m² and <30kg/m²) might increase the risk of severe illness from COVID-19, and is associated with increased risk of mechanical ventilation.[174][176][180][182]
A study in the US found a nonlinear (J-shaped) relationship between BMI and risk of hospitalization, intensive care admission, and death.[180] A study in the UK also found nonlinear associations between BMI and hospital admission and death due to COVID-19, and a linear association between BMI and intensive care admission due to COVID-19.[182] In the UK study, the relative risk due to increasing BMI was particularly notable in people younger than 40 years and of black ethnicity.
There is currently no high-quality research on the effects of weight loss on COVID-19, but that the role of excess weight as a risk factor for serious COVID-19 complications warrants further consideration.[177] For those living with obesity, weight loss has been shown to bring general long-term health benefits.
Patients with obesity who recover from COVID-19 may be at increased risk of postacute sequelae. One study found that patients with obesity who did not require ICU admission and survived the acute phase of COVID-19 had an increased risk of hospital admission and needing diagnostic tests over the subsequent 8 months compared with patients with normal BMI.[185]
Vaccination against COVID-19 is effective in people with overweight or obesity. Vaccination reduces the risk of COVID-19-related hospitalization 14 days or more after a second dose of vaccine by 68% in people with overweight and obesity, compared with 66% in people of healthy weight.[186]
go to our full topic on Osteoporosis
Guidelines from an international group of experts suggest altering the approach to management of osteoporosis during the current pandemic:[187]
- Zoledronic acid can be delayed for 6 to 9 months during the pandemic.
- Patients established on 6-monthly denosumab should continue without any delay and self-administration can be considered where appropriate. Pre-treatment checking of serum vitamin D and calcium levels can be waived and empiric treatment with cholecalciferol (vitamin D3) can be considered for all patients.
- Patients established on teriparatide, abaloparatide, or romosozumab should continue; however, periods of discontinuation for many weeks are unlikely to affect the long-term beneficial effects on fracture risk reduction.
- No new patients should be started on zoledronic acid, teriparatide, abaloparatide, or romosozumab due to the risk of confusion from potential adverse effects of the therapies and symptoms of COVID-19.
- If not contraindicated, alternative treatment, such as continuing with an oral bisphosphonate, should be considered.
The American Society of Bone and Mineral Research (ASBMR) has also published recommendations for the management of osteoporosis during the pandemic.[188]
The American College of Rheumatology advises that the denosumab dosing interval can be extended if necessary to minimize healthcare encounters, but should not exceed 8 months.[189]
Patients should be educated on the importance of continuing with calcium and vitamin D through supplements or diet, and lifestyle measures such as regular exercise and healthy diet.
go to our full topic on Palliative care
Patients with COVID-19 can deteriorate rapidly; treatment escalation plans should be put in place as soon as possible.[66]
Cough should initially be managed with nonpharmacologic measures if possible. Patients should be discouraged from lying on their back because this makes coughing ineffective. Simple measures, such as honey, may be used.[190]
A combination of opioid and benzodiazepine may be considered for people with COVID-19 and who have moderate to severe breathlessness, are distressed, and are at the end of life. Consider concomitant use of an antiemetic and regular stimulant laxative.[66]
Consider whether the sublingual, rectal, or subcutaneous route is appropriate for administration for medication; this may be easier for relatives or caregivers to administer if there are fewer healthcare staff.[66]
Implantable cardiac defibrillators (ICDs) cannot be deactivated remotely. If a patient with an ICD is receiving end of life care, the treating clinical team should secure a magnet to the skin over the ICD where possible, rather than using the programmer.[191]
Further resources are available at:
The World Hospice and Palliative Care Alliance: COVID-19 resources Opens in new window
go to our full topic on Psoriasis
People with inflammatory skin diseases have a higher risk of COVID-19 related death than the general population, after adjusting for confounding and mediating factors (HR 1.07, 96% CI 1.02 to 1.11). They are also at higher risk of hospital and critical care admission. South Asian people and mixed ethnicity people with inflammatory skin diseases are at higher risk of COVID-19-related death, compared with white people with inflammatory skin diseases.[192]
People taking tumor necrosis factor inhibitors, interleukin (IL)-12/IL-23 inhibitors, or IL-17 inhibitors do not have an increased risk of COVID-19-related critical care admission or death, compared with people taking standard systemic therapy (e.g., methotrexate).[192]
The National Psoriasis Foundation has published guidance for the management of psoriatic disease during the COVID-19 pandemic.[193] Patients and clinicians should make shared decisions regarding use of systemic therapies during the pandemic. In most cases, it is recommended that patients who do not have SARS-CoV-2 infection should continue biological or oral therapies.[193] Chronic systemic corticosteroids should be avoided if possible. If used, the dose should be tapered to the lowest therapeutic dose.[193] Initiation of systemic therapies should be discussed with patients who are newly diagnosed with psoriasis, because untreated psoriatic disease may lead to permanent joint damage and disability. Newly diagnosed patients, patients with unstable disease or flares, patients requiring a thorough skin and/or joint examination, and patients at risk for skin cancer should receive in-person care where pandemic conditions allow.[193]
The International Psoriasis Council recommends discontinuing or postponing the use of immunosuppressive medications in patients diagnosed with COVID-19.[194] Patients with psoriasis who become infected with SARS-CoV-2 should receive evidence-based therapies and supportive care. Systemic corticosteroids should not be withheld due to concern about a psoriasis flare following withdrawal. Dermatology and/or rheumatology consultation may be needed for hospitalized patients. Decisions about restarting treatments for psoriasis and psoriatic arthritis after recovery form COVID-19 should be made on a case-by-case basis.[193]
The National Psoriasis Foundation recommends that in most cases, patients should take the first mRNA-based vaccine for which they are eligible and they are offered. Systemic medication for psoriasis or psoriatic arthritis is not a contraindication to any of the available SARS-CoV-2 vaccines.[193] A 2-week interruption of methotrexate following a SARS-CoV-2 vaccine booster has been shown to boost antibody response.[195]
go to our full topic on Pulmonary embolism
The American Society of Hematology advises that normal D-dimer can be used to effectively rule out pulmonary embolism (PE) in patients with COVID-19. Radiologic imaging is not necessary if the D-dimer is normal in the context of low pretest probability. D-dimer is elevated in patients with COVID-19, particularly those with severe or critical disease, independent of the presence of venous thromboembolism (VTE). D-dimer cannot be used to diagnose VTE/PE in patients with COVID-19. If objective imaging to confirm or refute a diagnosis of VTE/PE is not feasible, clinicians should seek other evidence for VTE/PE. Clinical features that increase the likelihood of PE include symptoms or signs of deep vein thrombosis, unexplained hypotension or tachycardia, unexplained worsening respiratory status, and risk factors for thrombosis (e.g., history of thrombosis, cancer, hormonal therapy).[196]
Patients with COVID-19 who experience an incident thromboembolic event or who are highly suspected to have thromboembolic disease be managed with therapeutic anticoagulation.[148]
All hospitalized adults with COVID-19 should receive pharmacologic thromboprophylaxis, unless the risk of bleeding outweighs the risk of thrombosis.[196] Consult your local guidance for more information.
go to our full topic on Rheumatoid arthritis
Patients are advised to have influenza, whooping cough, and pertussis vaccinations.[197]
Clinicians are advised to engage patients with rheumatic disease in a shared decision-making process to discuss receiving a SARS-CoV-2 vaccine.[137][198] The response to vaccination is likely to be blunted in patients receiving systemic immunomodulatory therapies compared with the general population.[126][137][198] A 2-week interruption of methotrexate following a SARS-CoV-2 vaccine booster has been shown to boost antibody response.[195] A third dose of SARS-CoV-2 vaccine results in a serologic response in 84% of patients with immune-mediated inflammatory diseases who had a weak response to the standard 2-dose regimen.[126] The American College of Rheumatology advises that, beyond known allergies to vaccine components, there are no additional contraindications to SARS-CoV-2 vaccination for patients with autoimmune and inflammatory rheumatic diseases. Vaccination should ideally occur when rheumatologic disease is well controlled.[137] EULAR recommends that patients with rheumatic and musculoskeletal diseases are strongly advised to receive a SARS-CoV-2 vaccination with any of the vaccines approved in their country.[138]
go to our full topic on Sickle cell disease
Patients with sickle cell disease are at higher risk of severe disease and death if they become infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A registry of patients with sickle cell disease and COVID-19 in the US reported that the rate of hospitalization amongst adults with sickle cell disease was 69%, the intensive care admission rate was 11% and mortality was 7%.[199] A cohort study conducted in the UK reported a 4-fold increased risk of hospitalization with COVID-19, and a 2.5-fold increased risk of mortality from COVID-19, in people with sickle cell disease, compared with the general population.[200] Sickle cell trait is associated with increased risk of COVID-19 mortality and an increased incidence of acute kidney failure in the 60 days following COVID-19 diagnosis.[201]
The Sickle Cell Disease Association of America has published advice on reducing sickle cell disease morbidity during the COVID-19 pandemic. Patients should be advised to adhere carefully to their usual medication, to use a thermometer at home, and to seek prompt medical advice if they develop fever. Clinicians should ensure that patients have an adequate supply of medication to manage acute and chronic pain, and consider starting or optimizing therapies known to reduce acute sickle cell pain frequency to reduce the need for hospital attendance.[202]
Patients who have acute sickle cell pain without fever or signs of infection should be encouraged to manage pain with oral medication at home. Patients should be closely monitored, with a low threshold for arranging a face-to-face evaluation and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing.[202]
Patients with fever, cough, or shortness of breath require immediate evaluation for COVID-19. Care should include an assessment for other sources of infection with culture of blood (and other specimens as indicated), testing for typical viral infections, administering broad-spectrum antibiotics to cover encapsulated organisms, and assessing for acute chest syndrome. If the patient tests negative for SARS-CoV-2, home treatment with oral antibiotics and close monitoring may be appropriate. If possible, patients should be given an incentive spirometer to use at home.[202]
Patients with confirmed COVID-19 should be monitored closely for signs of rapidly progressive acute chest syndrome (thrombocytopenia, acute kidney injury, hepatic dysfunction, altered mental status, and multiorgan failure). The symptoms of acute chest syndrome may overlap significantly with symptoms of COVID-19. Standard care for acute chest syndrome should be given, including supplemental oxygen, empiric antibiotics, oseltamivir until influenza is excluded, incentive spirometry, and good pain control. Patients with worsening anemia, evidence of hypoxia, and chest x-ray changes should receive a transfusion of red blood cells. Clinicians should consider the possibility of undiagnosed pulmonary hypertension in acutely ill patients and be alert for signs of fat emboli syndrome. Signs of fat emboli syndrome include worsening anemia and mental status, hemolysis, thrombocytopenia, hypoalbuminemia, respiratory distress, and petechial rash; it may progress quickly and carries a high mortality. Patients who have COVID-19 and are discharged from the hospital remain at high risk of secondary bacterial infection and acute chest syndrome; they should be monitored daily.[202]
If availability of blood products is limited, the highest priority indications for chronic transfusion are: stroke prevention, progressive or critical neurovascular disease, recurrent acute chest syndrome unresponsive to hydroxyurea, and cardiovascular or respiratory comorbidity. Clinicians should assess whether patients can switch to hydroxyurea or whether transfusion strategy can be temporarily altered.[202]
go to our full topic on Strongyloides infection
Experts have made recommendations to reduce the risk ofStrongyloides hyperinfection or dissemination in people at moderate to high risk of Strongyloides infection. There is a risk of hyperinfection following exposure to immunosuppressive drugs. Chronic strongyloidiasis is often asymptomatic; suspicion should be based on risk factors including residence in an endemic area, rural residence, and exposure to soil during labour. A screen-and-treat strategy is recommended for patients at moderate to high risk ofStrongyloides infection without confirmed COVID-19, asymptomatic patients with a positive polymerase chain reaction test, and patients with mild COVID-19 who are not candidates for dexamethasone. Serologic testing is preferred. Patients in the hospital setting who are at moderate to high risk ofStrongyloides infection, are SARS-CoV-2 positive, and are initiating or are likely candidates for dexamethasone should be treated presumptively with ivermectin. Patients at moderate to high risk ofStrongyloides infection who have unexplained gram-negative rod infections after receiving dexamethasone or other immunosuppressive agents should have diagnostic testing forStrongyloides infection. Ivermectin should be given while awaiting results.[203]
go to our full topic on Syphilis
The US Food and Drug Administration has published an alert advising that false-positive Rapid Plasma Reagin (RPR) test results can occur when using the Bio-Rad Laboratories BioPlex 2200 Syphilis Total & RPR kit, in some people who have received a COVID-19 vaccine. Based on information provided by the manufacturer, Bio-Rad Laboratories, RPR false reactivity was observed in some individuals for at least five months following a COVID-19 vaccination.[204] Treponemal testing for syphilis such as Treponema pallidum particle agglutination (TP-PA) and treponemal immunoassays do not appear to be impacted by this issue and patients who received a reactive RPR result using the Bio-Rad BioPlex 2200 Syphilis Total & RPR test kit should be aware that they may need to be retested for syphilis with another test to confirm results.
go to our full topic on Systemic lupus erythematosus (SLE)
Hydroxychloroquine should be started at full dose for patients with newly diagnosed SLE. Hydroxychloroquine should be continued at the same dose during pregnancy.[189]
Belimumab, ACE inhibitors, angiotensin-II receptor antagonists, and glucocorticoids may be initiated if indicated. High-dose glucocorticoids or immunosuppressants may be initiated for patients with lupus nephritis. Glucocorticoids should not be stopped abruptly and should be used at the lowest possible dose to control disease.[189]
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be continued following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure, but should be stopped if the patient develops severe COVID-19.[189] Hydroxychloroquine should be stopped temporarily if the patient develops COVID-19.[189]
Following recovery from COVID-19, US guidelines recommend that rheumatic disease treatments can be restarted within 7-14 days of symptom resolution in patients with mild or no pneumonia who were treated in the ambulatory setting or with self quarantine. Decisions regarding restarting rheumatic disease therapies in patients who had more severe COVID-19 should be taken on an individual basis. If a patient had a positive polymerase chain reaction test for SARS-CoV-2 but has remained asymptomatic, rheumatic disease treatments may be restarted 10-17 days after the positive test result.[189]
Clinicians are advised to engage patients with rheumatic disease in a shared decision-making process to discuss receiving a SARS-CoV-2 vaccine. The response to vaccination is likely to be blunted in patients receiving systemic immunomodulatory therapies compared with the general population. The American College of Rheumatology advises that, beyond known allergies to vaccine components, there are no additional contraindications to SARS-CoV-2 vaccination for patients with autoimmune and inflammatory rheumatic diseases. Vaccination should ideally occur when rheumatologic disease is well controlled.[137] EULAR recommends that patients with rheumatic and musculoskeletal diseases are strongly advised to receive a SARS-CoV-2 vaccination with any of the vaccines approved in their country.[138]
go to our full topic on Systemic vasculitis
A cohort study conducted in the UK reported that the most common symptoms of COVID-19 in patients with systemic vasculitis were dyspnea, fever, and cough. The most common complications were respiratory failure (54%), acute kidney injury (18%), and secondary infection (15%). Over 90% of patients were admitted to hospital, and 28% died. Comorbid respiratory disease and glucocorticoid exposure were associated with severe outcomes; subtype of vasculitis and vasculitis disease activity were not.[205]
Patients should follow general infection prevention precautions, e.g., hand hygiene and social distancing. Some measures to reduce healthcare encounters (and potential severe acute respiratory syndrome coronavirus 2 exposure) may be appropriate; clinicians and patients should make a shared decision. Glucocorticoids should be used at the lowest dose to control disease and should not be stopped abruptly, regardless of infection or exposure status.[206]
High-dose glucocorticoids or other immunosuppressants may be initiated if indicated for patients with systemic inflammatory or vital organ-threatening disease.[206]
Clinicians are advised to engage patients with rheumatic disease in a shared decision-making process to discuss receiving a SARS-CoV-2 vaccine. The response to vaccination is likely to be blunted in patients receiving systemic immunomodulatory therapies compared with the general population. The American College of Rheumatology advises that, beyond known allergies to vaccine components, there are no additional contraindications to SARS-CoV-2 vaccination for patients with autoimmune and inflammatory rheumatic diseases. Vaccination should ideally occur when rheumatological disease is well controlled.[137] EULAR recommends that patients with rheumatic and musculoskeletal diseases are strongly advised to receive a SARS-CoV-2 vaccination with any of the vaccines approved in their country.[138]
go to our full topic on Thalassemia
The American Society of Hematology has published recommendations for the treatment of thalassemia during the pandemic.[207] They advise that blood transfusion and luspatercept should be continued as usual. Iron chelation should be continued in well patients. If a patient develops COVID-19 then interruption of iron chelation is usually advisable; the case should be discussed with the patient's hematologist. Febrile, splenectomized patients should be investigated for bacterial infection and receive empiric antibiotics to cover secondary bacterial infections.[207]
The Thalassaemia International Federation (TIF) has published a position statement suggesting management strategies during the pandemic, covering patients’ risk level, adaptation of hemoglobinopathy care, safety of blood transfusions, blood supply challenges, and lifestyle and nutritional considerations.[208]
go to our full topic on Thrombotic thrombocytopenic purpura
Plasma exchange remains the recommended initial treatment for immune-mediated thrombotic thrombocytopenic purpura (iTTP). Corticosteroids and rituximab should still be used in treatment of acute iTTP. Patients with severely deficient ADAMTS13 activity may still receive rituximab to prevent relapse; the potential increased risk of COVID-19 complications should be balanced against the benefit of delaying or preventing relapses of iTTP. If access to plasma exchange is limited, the patient should ideally be transferred to a facility that can offer plasma exchange; otherwise, caplacizumab and immunosuppressive therapy alone may be considered.[209]
If a patient develops COVID-19, plasma exchange should be used in the same way as for other patients; the risks and benefits of corticosteroids and rituximab should be carefully considered. Caplacizumab may be used in conjunction with plasma exchange as a temporizing measure to protect from exacerbations and relapses until recovery from COVID-19; after recovery, corticosteroids and/or rituximab may be used to increase ADAMTS13 activity.[209]
Trials of severe acute respiratory syndrome coronavirus 2 vaccination in patients with hematological conditions are lacking. Such patients are likely to have an attenuated response to vaccination. Additional measures, such as early vaccination of household contacts, may be considered.[76]
go to our full topic on Tuberculosis
Coinfection with tuberculosis (TB) and COVID-19 is common globally, and is associated with higher mortality than infection with COVID-19 alone. The mean in-hospital fatality rates for TB and COVID-19 coinfection are 6.5% in high-income countries, and 22.5% in low/middle-income countries.[210]
Symptoms of tuberculosis may mimic those of COVID-19, and testing for tuberculosis may be considered in selected patients presenting with COVID-19.[211]
The Centers for Disease Control and Prevention advise that administration of mRNA COVID-19 vaccines should not be delayed because of testing for tuberculosis (TB) infection. Immune-based testing (tuberculin skin testing or interferon-release assay) may be done before or at the same time as COVID-19 vaccination. If this is not possible, immune-based testing should be delayed for at least 4 weeks after completion of COVID-19 vaccination, but generally should not be cancelled. Patients who have active TB, or an illness that is being evaluated as active TB, may receive COVID-19 vaccination. Severe or acute illness is a precaution to administration of all vaccines. Patients who have symptoms or other diagnostic findings consistent with active TB should receive further evaluation, regardless of immune based testing results.[212]
The UK National Health Service advises that an interferon-release assay blood test may be used instead of tuberculin skin testing for contact tracing to reduce person-to-person contact during the pandemic. Testing for latent tuberculosis and neonatal Bacillus Calmette-Guérin vaccination should continue.[213]
go to our full topic on Ulcerative colitis
People with inflammatory bowel disease are at increased risk of COVID-19-related critical care admission or death, compared with the general population, after adjusting for confounding and mediating factors (HR 1.08, 95% CI 1.01 to 1.16). South Asian, black, and mixed ethnicity people with inflammatory bowel disease have a higher risk of COVID-19-related death, compared with white people with inflammatory bowel disease.[192]
Patients taking JAK inhibitors have an increased risk of COVID-19 related hospital admission, compared with patients on standard systemic therapy.[192]
Blood tests to monitor response to therapy should be performed at the minimum safe frequency.[214] International guidelines recommend that patients stop taking methotrexate, thiopurines, or tofacitinib if they develop COVID-19. Detailed recommendations for stopping and restarting medications are given depending on the level of IBD activity and severity of COVID-19 infection.[122][123] Decisions on surgery should be individualized for each patient with a multidisciplinary team.[124]
The British Society of Gastroenterology has published a position statement strongly supporting SARS-CoV-2 vaccination for patients with UC.[125] A third dose (or booster dose) of SARS-CoV-2 vaccine is also recommended for all patients with IBD receiving immunosuppressive treatment and all patients with IBD who are extremely clinically vulnerable. A third dose of SARS-CoV-2 vaccine results in a serologic response in 84% of patients with immune-mediated inflammatory diseases who had a weak response to the standard 2-dose regimen.[126] Some immunosuppressive therapies may impact efficacy of COVID-19 vaccines in patients with IBD, and this should be considered in the timing of vaccinations.[126][127]
Prognostic models for predicting the probability of adverse COVID-19 outcomes in patients with IBD are being developed.[128]
go to our full topic on Uveitis
The International Uveitis Study Group has published consensus recommendations on the management of patients with uveitis during the COVID-19 pandemic. Patients without symptoms of COVID-19 should continue on their usual immunosuppressive treatment. Patients with symptoms or signs of COVID-19 should be tested as soon as possible to confirm the diagnosis. Immunosuppressive treatment, except tocilizumab or interferon, should be stopped. Slow reduction of systemic corticosteroids should be discussed with the treating medical team. Patients who are asymptomatic and test positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) should continue immunosuppressive therapy. The dose should be reduced if their white blood cell count falls below 4000 cells/microlitre.[215]
Patients who are due to start immunosuppressive treatment should be tested for SARS-CoV-2 in addition to the usual screen for infectious diseases. Consideration may be given to using local or regional corticosteroids as bridging therapy to delay the start of systemic immunosuppression. Patients with Behcet’s disease may require first-line systemic therapy; if so, self administered injections to reduce hospital outpatient visits could be considered.[216]
go to our full topic on Viral gastroenteritis
COVID-19 may present with gastrointestinal (GI) symptoms that mimic viral gastroenteritis. The estimated pooled prevalence of GI symptoms in patients with COVID-19 varies from less than 10% to 15%.[149][217] Nausea or vomiting, anorexia, and diarrhea are the most common manifestations.[217] Patients with severe COVID-19 had higher rates of GI symptoms than those with less severe disease. Most patients with GI symptoms and COVID-19 have concomitant respiratory symptoms or fever; 3% of patients reported GI symptoms only.[218] Patients may present with nausea or diarrhea 1 to 2 days prior to onset of fever and breathing difficulties.[219] A retrospective cohort study found that median duration of viral shedding in stool samples was 22 days, compared with 18 days in respiratory samples and 16 days in serum samples. The median duration of shedding was lower in mild illness (14 days) compared to severe illness (21 days).[220]
Guidelines from the American Gastroenterological Association (AGA) recommend that outpatients with new-onset diarrhea are asked about high risk contact exposure, whether they have a history of COVID-19-associated symptoms, and whether they have other GI symptoms (nausea, vomiting, abdominal pain).[149] Patients with new-onset GI symptoms should be monitored for symptoms of COVID-19, as GI symptoms may precede other COVID-related symptoms by a few days. Currently, there is not enough evidence to support stool testing for diagnosis or monitoring of COVID-19 as part of routine clinical practice.[149] In hospitalized patients with known or suspected COVID-19, the AGA recommends obtaining a thorough history of GI symptoms, including onset, characteristics, duration, and severity.
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