Treating asthmatic patients during the COVID-19 pandemic

Viruses are known to trigger asthma exacerbations. During the early stages of the COVID-19 pandemic, the CDC listed moderate to severe asthma as an underlying condition that may put one at risk for moderate to severe COVID-19 if they were infected with SARS-CoV2¹. Some of the early data reported in April 2020 from CDC Morbidity and Mortality Weekly Report suggested asthma may be a risk factor with 17% of hospitalized patients having a diagnosis of asthma². However, as we collect more data about COVID-19, some studies suggest asthma may not be a risk factor (although studies in the pediatric population are lacking³). When examining the New York State COVID-19 data, it is not among the top 10 conditions associated with death⁴. In a study of 1526 patients, from a large US health system, with PCR confirmed COVID-19 and an asthma prevalence of 14%, asthma was not associated with an increased risk of hospitalization⁵.

Moreover, the paradigm in which we think about the relationship between asthma and COVID-19 continues to rapidly evolve. The authors of one study hypothesized that respiratory allergies and allergic asthma may be protective against COVID-19 because of lower ACE-2 gene expression⁶. In another study by Peters et. al, the authors hypothesized that higher expression of ACE-2 in sputum cells of African Americans with asthma may contribute to higher morbidity in COVID-19⁷. In one study, patients with both asthma and obesity had higher morbidity and asthma was independently associated with prolonged intubation⁸. In a recent study of primary care records from approximately 17 million people in the UK, severe asthma was identified as a risk factor for death from COVID-19⁹.

Based on the conflicting studies, the CDC recently revised their guidelines and established two categories: 1) conditions that increase risk and 2) conditions that “might” increase risk for moderate to severe COVID-19 and moderate to severe asthma is in the latter category. However, asthma control continues to be a top priority during this pandemic because patients and their caregivers may be reluctant to seek medical services due to they fears of being exposed to COVID-19, so it is important to optimize asthma control and try to prevent asthma exacerbations when possible¹⁰. The list below identifies some barriers to achieving optimal asthma control and solutions but does not identify all barriers and solutions.

Barriers to achieving optimal asthma control

• Medication adherence: Some patients may find it difficult to remember to take their medications or may be less motivated to take medications when they are feeling well. The statistics for inhaler adherence is poor with <50% of children and 30-70% of adults taking their asthma medications as prescribed¹¹.
• Inhaler Technique: Many patients do not use their inhaler properly. In the GINA 2019 report, it was estimated that 70-80% of patients do not demonstrate proper inhaler technique¹².
• Trigger identification: Many patients cannot readily identify their asthma triggers. Some examples of common asthma triggers include environmental allergens (dust mites, pollens, mold, animal dander, cockroach, mouse), viruses, and environmental tobacco smoke exposure¹³.

Solutions for achieving optimal asthma control 

• Review inhaler technique
• Asthma action plans—document the plan and advise patients on when it is appropriate to escalate their medications and when they should call their healthcare provider or seek emergency services. Empower patients to take an active role in managing their disease.
• Identify triggers and perform environmental remediation - The majority of asthma is allergic---up to 90%¹⁴in children and 60% in adults¹⁵. Specific IgE testing to common environmental allergens combined with a patient’s history can help identify allergic triggers¹⁶. Minimizing exposure to allergens based on a patient’s allergen sensitization pattern can help improve asthma symptoms¹⁷.

During these challenging, when a cough or a sneeze may have patients on edge, it is important to focus on preventative measures and try to optimize asthma control and prevent asthma exacerbations.

_References

1. _{https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fgroups-at-higher-risk.html​}
   
2. _{https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6915e3-H.pdf} 
   
3. _{Castro-Rodriguez JA, Forno E. Asthma and COVID-19 in children: A systematic review and call for data [published online ahead of print, 2020 Jun 18]. Pediatr Pulmonol. 2020;10.1002/ppul.24909. doi:10.1002/ppul.24909}
   
4. _{https://covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Fatalities?%3Aembed=yes&%3Atoolbar=no&%3Atabs=n} 
   
5. _{Chhiba KD, Patel GB, Vu THT, et al. Prevalence and characterization of asthma in hospitalized and non-hospitalized patients with COVID-19 [published online ahead of print, 2020 Jun 15]. J Allergy Clin Immunol. 2020;S0091-6749(20)30840-X. doi:10.1016/j.jaci.2020.06.010}
   
6. _{Jackson DJ, Busse WW, Bacharier LB, et al. Association of respiratory allergy, asthma, and expression of the SARS-CoV-2 receptor ACE2 [published online ahead of print, 2020 Apr 22]. J Allergy Clin Immunol. 2020;S0091-6749(20)30551-0. doi:10.1016/j.jaci.2020.04.009} 
   
7. _{Peters MC, Sajuthi S, Deford P, et al. COVID-19 Related Genes in Sputum Cells in Asthma: Relationship to Demographic Features and Corticosteroids [published online ahead of print, 2020 Apr 29]. Am J Respir Crit Care Med. 2020;10.1164/rccm.202003-0821OC. doi:10.1164/rccm.202003-0821OC} 
   
8. _{Mahdavinia M, Foster KJ, Jauregui E, et al. Asthma prolongs intubation in COVID-19 [published online ahead of print, 2020 May 14]. J Allergy Clin Immunol Pract. 2020;S2213-2198(20)30476-1. doi:10.1016/j.jaip.2020.05.006} 
   
9. _{Williamson, E.J., Walker, A.J., Bhaskaran, K. et al. OpenSAFELY: factors associated with COVID-19 death in 17 million patients. Nature (2020). https://doi.org/10.1038/s41586-020-2521-4}​
   
10. _{Oreskovic NM, Kinane TB, Aryee E, Kuhlthau KA, Perrin JM. The Unexpected Risks of COVID-19 on Asthma Control in Children [published online ahead of print, 2020 Jun 1]. J Allergy Clin Immunol Pract. 2020;S2213-2198(20)30523-7. doi:10.1016/j.jaip.2020.05.027}
    
11. _{Engelkes M, Janssens HM, de Jongste JC, Sturkenboom MC, Verhamme KM. Medication adherence and the risk of severe asthma exacerbations: a systematic review. Eur Respir J. 2015;45(2):396-407. doi:10.1183/09031936.00075614}
    
12. _{Global Initiative for Asthma (GINA). Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2019. http://ginasthma.org/gina‐reports/}
    
    
13. _{Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med. 2004;351(11):1068-1080. doi:10.1056/NEJMoa032097}
    
    
14. _{Høst A, Halken S. The role of allergy in childhood asthma. Allergy. 2000;55(7):600-608. doi:10.1034/j.1398-9995.2000.00122.x}
    
    
15. _{Allen-Ramey F, Schoenwetter WF, Weiss TW, Westerman D, Majid N, Markson LE. Sensitization to common allergens in adults with asthma. J Am Board Fam Pract. 2005;18(5):434-439. doi:10.3122/jabfm.18.5.434}
    
    
16. _{National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007 [published correction appears in J Allergy Clin Immunol. 2008 Jun;121(6):1330]. J Allergy Clin Immunol. 2007;120(5 Suppl):S94-S138. doi:10.1016/j.jaci.2007.09.043}
    
    
17. _{Janson SL, McGrath KW, Covington JK, Cheng SC, Boushey HA. Individualized asthma self-management improves medication adherence and markers of asthma control. J Allergy Clin Immunol. 2009;123(4):840-846. doi:10.1016/j.jaci.2009.01.053}