Co-Morbidity Based Questions

Frequently Asked Inpatient Questions Microchapter

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Ogechukwu Hannah Nnabude, MD Rinky Agnes Botleroo, M.B.B.S.Gurmandeep Singh Sandhu,M.B.B.S.[2] Aisha Adigun, B.Sc., M.D.[3]

## Co-Morbidity Based Questions

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### Patients with Hypertension

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#### Should ACE Inhibitors and ARBs be discontinued in patients on admission for COVID-19?

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* No. The American Heart Association, the Heart Failure Society of America and the American College of Cardiology recommend continuing ACE-I or ARB medications for all patients already prescribed those medications for indications such as heart failure, hypertension, or ischemic heart disease.
* At this time, the available evidence demonstrates no indication of COVID-specific harm from these agents. Several randomized controlled trials are underway to better answer this important clinical question.
* Cardiovascular disease patients diagnosed with COVID-19 should be fully evaluated by a healthcare professional before adding or removing any treatments, and any changes to their treatment should be based on the latest scientific evidence. Patients who rely on ACE-Is or ARBs to treat chronic conditions and have additional questions should speak to their healthcare provider for individualized management.

### Patients with Asthma

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#### Should an Asthma exacerbation be managed any differently to reduce the risk of COVID-19?

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* The selection of therapeutic options through the guideline-recommended treatment of asthma exacerbation has not been affected by what we currently know about COVID-19.
* Systemic corticosteroids should be used to treat an asthma exacerbation per national asthma guidelines and current standards of care, even if it is caused by COVID-19.
* Short-term use of systemic corticosteroids to treat asthma exacerbation should be continued. There is currently no evidence to suggest that short-term use of systemic corticosteroids to treat asthma exacerbation increases the risk of developing severe COVID-19, whereas there is an abundance of data to support the use of systemic steroids for moderate or severe asthma exacerbation.
* Patients with asthma but without symptoms or a diagnosis of COVID-19 should continue any required nebulizer for treatments, as recommended by national professional organizations.
* If healthcare providers need to be present during nebulizer use among patients who have either symptoms or a diagnosis of COVID-19, they should use recommended precautions when performing aerosol-generating procedures (AGPs).
* If clinicians are concerned that an asthma exacerbation is related to an underlying infection with COVID-19, clinicians can access laboratory testing for COVID-19 through a network of state and local public health laboratories across the country.

#### Are any changes recommended to the treatment plan of an asthma patient with COVID 19?

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* If patients with asthma who have symptoms or a diagnosis of COVID-19 need to use nebulizer at home, it is recommended by national professional organizations that they should use the nebulizer in a location that minimizes and preferably avoids exposure to any other members of the household, and preferably a location where the air is not recirculated into the home (like a porch, patio, or garage). Limiting the number of people in the room or location where the nebulizer is used is also recommended. Nebulizers should be used and cleaned according to the manufacturer’s instructions.[1]
* If nebulizer use in a healthcare setting is necessary for patients who have either symptoms or a diagnosis of COVID-19, they must use recommended precautions when performing aerosol-generating procedures (AGPs).

### Patients currently Undergoing Hemo-dialysis

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#### Should I go to my dialysis treatments?

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* Yes, you must go to all your dialysis treatments. Missing even one treatment can make you very sick or lead to death. Dialysis centers have been given strict guidelines on how to keep you safe from COVID-19. The Centers for Disease Control has issued interim guidance for patients on dialysis who have COVID-19 and all centers should be following these guidelines.
* Everyone, including all patients receiving treatment at the center, home dialysis patients, staff, and visitors who may have been exposed to the coronavirus, and people who currently have symptoms of COVID-19 should be asked if they:
* have had any fevers or any breathing or respiratory (lung) symptoms
* live in an area with confirmed COVID-19 cases
* had contact with someone who is being checked for COVID-19, or if they have recently been in another country where COVID-19 has spread
* Centers should take patients’ temperatures at check-in.
* Have separate waiting areas for sick patients that are at least six feet from other patients (some centers allow healthy patients to wait outside or in their cars until it’s their turn to be seen)
* Patients with respiratory symptoms should be given wear masks to wear and they should be dialyzing six feet away in all directions from healthy patients. In some centers, patients with respiratory symptoms may be dialyzed in a separate area.
* Visitors with signs/symptoms of infection should not be permitted to enter the dialysis center
* Use cleaning procedures that kill the coronavirus, along with all routine cleaning and disinfection procedures.[2]

#### Can I be denied dialysis treatment if I have COVID-19?

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* No. People who are on dialysis and who have also contracted COVID-19 are considered to be at high-risk. If there is availability, these patients may even be admitted to a hospital.
* In the event your symptoms are mild, you should be able to go to your dialysis center for your scheduled treatments. If you have a confirmed case of COVID-19, or have symptoms of COVID-19, or believe you may have been exposed to the coronavirus, then call your dialysis center prior to your scheduled appointment as there may be new procedures they would like you to follow.[2]

#### Do patients with suspected or confirmed COVID-19 need to wear masks during their dialysis treatment?

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* Patients receiving dialysis in their own room or an isolation room do not need to wear a mask if the dialysis staff is working from outside the room.
* If the dialysis staff is in the room with the patient, the patient should wear a facemask if tolerated.
* Dialysis staff in the room should use all recommended PPE (Personal Protective Equipment).
* When patients with confirmed COVID-19 are being dialyzed in the acute dialysis unit, the patient should wear a facemask for the duration of treatment.
* Dialysis staff in the room should adhere to appropriate transmission-based Precautions and use all recommended PPE.

#### Where should intermittent hemodialysis be performed in the acute care setting?

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* For patients with suspected or confirmed COVID-19 requiring intermittent hemodialysis in the acute care setting, dialysis should ideally be performed in the patient’s hospital room with the door closed. This serves to limit the patient’s movement within the hospital.

* If the patient is to be dialyzed in the acute care dialysis unit, consider the following:

* Transporting the patient to the acute care dialysis unit:

When a patient with suspected or confirmed COVID-19 is being transported to the acute care dialysis unit, ensure HCP(Health Care Personnel) adhere to recommended infection control practices like using personal protective equipment. The patient should wear a facemask during transportation.

*     * Dialyzing patient in an acute care dialysis unit isolation room:

If the acute care dialysis unit has an isolation room, hemodialysis should be performed in the isolation room with the door closed. Hepatitis B isolation rooms should only be used for dialysis patients with confirmed or suspected COVID-19 if:

1. The patient is hepatitis B surface antigen-positive or
2. The facility has no patients on the census with hepatitis B infection who would require treatment in the isolation room.

The isolation room should be terminally cleaned after the care of each patient with COVID-19.

*     * Dialyzing several patients with confirmed COVID-19 in a shared room in the acute care dialysis unit:

In a situation where there are several patients with confirmed COVID-19 requiring hemodialysis (non-ICU), consider cohorting the patients on the same dialysis shift, preferably the last dialysis shift of the day to allow for terminal cleaning of the dialysis unit following treatment.

*     * If possible, patients without COVID-19 should not receive dialysis during the same shift (in the same room); if patients without COVID-19 are dialyzed at the same time in the unit, they should be kept at least 6 feet away from the COVID-19 patients at all times. Patients with confirmed or suspected COVID-19 should continue to wear their facemask during treatment and adhere to appropriate respiratory hygiene and cough etiquette.

#### Can dialysis patients recover from COVID-19?

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* High-risk patients, such as those on dialysis, may be at higher risk for severe disease from COVID-19.For severe cases, recovery may take 6 weeks or more. About 1% those infected will die from the disease.[2]

### Cancer Patients

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#### Can/Should Cancer surgery be delayed? What about radiation therapy?

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* Because every case is unique, decisions on whether or not to postpone cancer treatment and care should be made on a patient-by-patient basis with the physician. Patients should contact their physician or health care providers' office for any concerns they may have. [3]

#### Should immune-suppressive treatments be discontinued or delayed?

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* If you take medications that weaken your immune system, called immunosuppressant medications:

1. Do not change or stop taking medicines without talking to your doctor. Stopping or changing medicine can cause serious health problems.[4]

* Among the biologicals, the theoretical risk of COVID‐19 infection seems to be higher with inhibitors of {{tumor necrosis factor-alpha{{ (TNF‐α) compared to interleukin (IL) inhibitors. Among the TNF‐α, the risk seems to be somewhat increased with infliximab and its biosimilars. In general, TNF‐α is not recommended during infectious diseases.

* Ustekinumab, risankizumab, ixekizumab, and brodalumab do not increase the risk of respiratory infections in general. However, the data should be interpreted with caution, since we do not have the data for COVID‐19 yet.

* There are reports on drug‐induced interstitial lung disease by infliximab adalimumab, and ustekinumab. Patients on these medications with pre-existent pulmonary problems have a higher risk for COVID‐19.

#### Should patients take an antiviral medication such as Tami flu for protection?

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* Oseltamivir(branded as Tamiflu) is a drug approved for the treatment of influenza A and B. Oseltamivir targets the neuraminidase distributed on the surface of the influenza virus to inhibit the spread of the influenza virus in the human body. A study in Wuhan reported that no positive outcomes were observed after receiving antiviral treatment with oseltamivir.
* Several clinical trials are still evaluating the effectiveness of oseltamivir in treating SARS-CoV-2 infection. Oseltamivir is also used in clinical trials in several combinations, such as with chloroquine and favipiravir.

### Patients with HIV

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#### Do patients with HIV have a higher risk of contracting COVID-19?

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* There is no evidence that suggests that HIV patients who are on effective antiretroviral treatments and who have adequate CD4 counts are at increased risk of contracting COVID-19.[5]
* Individuals with weakened immunity, i.e. HIV patients who are not on effective antiretroviral medication or those with low CD4 counts and have other comorbidities may be at increased risk of severe illness from COVID-19.[5][6]

## References

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1. ↑ "Clinical Questions about COVID-19: Questions and Answers | CDC".
2. ↑ 2.0 2.1 2.2 "Dialysis & COVID-19 | National Kidney Foundation".
3. ↑ "FAQ: Coronavirus and Patients with Cancer | Patient Education | UCSF Health".
4. ↑ "If You Are Immunocompromised, Protect Yourself From COVID-19 | CDC".
5. ↑ 5.0 5.1 "What to Know About HIV and COVID-19 | CDC".
6. ↑ Dima Dandachi, MD, MPH, Grant Geiger, BS, Mary W Montgomery, MD, Savannah Karmen-Tuohy, BS, Mojgan Golzy, Ph.D, Annukka A R Antar, MD, Ph.D, Josep M Llibre, MD, Ph.D, Maraya Camazine, MS, Alberto Díaz-De Santiago, MD, Ph.D, Philip M Carlucci, BS, Ioannis M Zacharioudakis, MD, Joseph Rahimian, MD, Celestine N Wanjalla, MD Ph.D, Jihad Slim, MD, Folasade Arinze, MD, MPH, Ann Marie Porreca Kratz, PharmD, BCPS, BCIDP, Joyce L Jones, MD, MS, Shital M Patel, MD, MS, Ellen Kitchell, MD, Adero Francis, MD, Manoj Ray, MD, David E Koren, PharmD, John W Baddley, MD, MSPH, Brannon Hill, PharmD, Paul E Sax, MD, Jeremy Chow, MD, MS, HIV-COVID-19 consortium, Characteristics, Comorbidities, and Outcomes in a Multicenter Registry of Patients with HIV and Coronavirus Disease-19, Clinical Infectious Diseases, , ciaa1339, https://doi.org/10.1093/cid/ciaa1339