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CME

COVID-19 and Special Populations

Overview

Cancer

  • cancer patients may be at higher risk for developing severe COVID-19, including those
    • receiving chemotherapy, or who received chemotherapy ≤ 3 months
    • receiving extensive radiation therapy
    • who received bone marrow or stem cell transplantation ≤ 6 months, or still treated with immunosuppressive drugs
    • with some types of hematologic cancer that damages immune system (such as chronic leukemia, lymphoma, or myeloma), even if they did not receive treatment
    • with impaired immune system due to leukocytopenia, low immunoglobulin levels, or long-lasting immunosuppression
  • both cancer or history of cancer and anticancer treatment ≤ 14 days before COVID-19 diagnosis appear to be associated with increased risk of severe illness
  • patient and caregiver safety recommendations for oncology practices during COVID-19 include limiting exposure to patients and staff, utilization of telemedicine, and rescheduling/postponing nonurgent appointments
  • evaluation of cancer patients for COVID-19
    • may have atypical presentation or present with mild symptoms and deteriorate rapidly
    • consider that symptoms of neutropenic sepsis and pneumonitis related to therapy can mimic symptoms of COVID-19
    • PubMed32170865Journal of medical virologyJ Med Virol20200314lymphopenia may already be present in oncology patients due to disease or treatment; early studies suggest lymphopenia may be common in COVID-19 patients
    • may be considered priority for testing if symptomatic
  • cancer screening and diagnosis/staging considerations
    • consider postponing screening procedures requiring clinic visits and diagnosis and staging interventions for patients who are suspected of disease at low risk of rapid progression
    • carefully weigh risk and benefits of delaying screening procedures
    • limit staging procedures to those most needed to inform development of initial care plan
  • management considerations for medical oncology patients
    • consider delay or alteration of treatment for patients currently receiving or about to receive chemotherapy due to theoretical increased risk of contracting COVID-19 given immunosuppressive effects of treatment
    • for patients with solid tumors
      • for therapy with definitive intent, consider proceeding with adjuvant therapy
      • for progressive or metastatic disease, delay in treatment may result in worsening symptoms, leading to decreased performance status and inability to receive further treatment
      • surgeries may need to be postponed due to lack of hospital resources
    • PubMed32173855British journal of haematologyBr J Haematol20200315for patients with hematologic malignancies
      • aggressive disease may require to proceed with high-dose therapy and hematopoietic stem cell transplantation (HSCT) with definitive intent
      • consider decreasing immunosuppressive medications or dosing of chemotherapy if feasible
      • decisions on the benefits and risks of continuation of maintenance chemotherapy will have to be taken if the infection rates increase
    • for patients with late-stage disease or with comorbid conditions who may become infected with COVID-19
      • consider which treatment would have the most success and benefit
      • consider prognosis if patient would require mechanical ventilation
      • conduct proactive palliative and end-of-life conversations as soon as possible
    • supportive care
      • attempt to decrease transfusions when possible anticipating blood product shortages
      • consider limiting or postponing supportive therapies, such as bisphosphonate therapy
    • neutropenic fever
      • for prophylaxis, monitor neutrophil count and consider growth factor for treatment regimens at lower level of expected risk (> 10% risk) to minimize risk of neutropenic fever
      • for acute care, prescribe prophylactic empiric antibiotics in patients who are febrile and neutropenic but clinically stable as determined by tele-evaluation or by phone; further evaluation should be done outside emergency department
  • management considerations for bone marrow and stem cell transplant patients
    • defer nonurgent transplants whenever possible
    • HSCT often requires extended hospital stay and prolonged immunosuppression therapy
    • depending on status and risk of disease recurrence, delaying HSCT may not be possible
      • if low-risk disease, consider deferring HSCT process for several weeks to months
      • if high-risk disease, consider deferring until asymptomatic with negative polymerase chain reaction (PCR) testing
    • PubMed32180224British journal of haematologyBr J Haematol20200316consider performing HSCT in outpatient center for appropriate cases
  • management considerations for cancer surgery patients
    • considerations may vary depending on type of primary cancer including breast cancer, thoracic cancers, colorectal cancer, gastrointestinal and hepatobiliary cancers, endocrine and head and neck cancers, gynecologic cancers, peritoneal surface malignancies, and sarcomas
    • American College of Surgeons (ACS) guidance regarding surgery and COVID-19
      • consider availability of local institution resources, including protective gear for providers and patients
      • for elective cases with high likelihood of need for postoperative intensive care unit or respirator utilization, balance risk of surgery delay to imminent availability of resources for patients with COVID-19
      • consult multidisciplinary experts to consider individual cases, or for institutions with high case volumes to establish triage criteria based on local circumstances
    • American Society of Clinical Oncology (ASCO) guidance for COVID-19 and cancer surgery
      • consider postponing elective surgeries if feasible; however, make individual determinations of potential risks of delaying cancer-related surgery
      • in certain situations where neoadjuvant therapy is an option but not routinely considered (such as early stage breast cancer), consider neoadjuvant therapy instead of surgery or simply delaying surgery
        • weigh risk of delay in definitive surgery against potential burden of case complexity and patient risk of exposure to COVID-19
        • also consider risks of exposure to COVID-19 if neoadjuvant therapy is immunosuppressive or requires clinic visits and clinician-patient contact
  • management considerations for radiation therapy patients
    • consider risks of delaying treatment in patients with potentially curable cancer
    • nonurgent cases that may be delayed up to 2 months include patients with prostate cancer, certain breast cancer (hormone receptor positive), and benign central nervous system, such as meningiomas and schwannomas
    • patients undergoing palliative care may also experience delays except patients with life-threatening or function-threatening situations (for example, spinal cord compression, cranial nerve compression, airway obstruction, hemoptysis, or superior vena cava syndrome)
  • considerations for palliative radiation therapy patients
    • offer short course of palliative radiation therapy to high-priority patients with life expectancy longer than days to weeks
    • priority of palliative radiation therapy is based on treatment indications
      • high priority may include patients with metastatic cancer requiring palliative radiation therapy for oncologic emergencies including brain metastases, spinal chord compression, tumor bleeding, and superior vena cava syndrome and airway obstruction
      • medium priority may include patients with symptomatic disease without oncologic emergency (such as symptomatic bone metastases) and asymptomatic disease for which radiation therapy is recommended to prevent imminent functional deficit
      • low priority may include patients with symptomatic or asymptomatic disease for which radiation therapy is an option
  • see also COVID-19 and Patients With Cancer for details

Cardiovascular Disease

  • patients with preexisting cardiovascular disease may be more susceptible to COVID-19 infection, and may be at increased risk of death, especially when patients present with elevated troponin T levels, where the mortality may be three-fold higher (69.4% vs. 23%) compared to those without cardiovascular disease
    • Coronavirus Disease 2019 (COVID-19) disease is an acute respiratory disease caused by an infection with a novel coronavirus SARS-CoV-2 (CDC 2020 Mar 22)
    • patients who have COVID-19 may be at risk of developing cardiac complications, especially acute cardiac injury and arrhythmias; acute myocardial injury may be more common in patients with preexisting cardiovascular disease and may be associated with increased morbidity and mortality
    • clinical presentation and diagnosis of COVID-19 in patients with preexisting cardiovascular disease or COVID-19-related myocardial injury
      • diagnosis of COVID-19 may be challenging in patients with atypical presentation or preexisting cardiovascular disease
        • patients may rarely initially present with cardiovascular symptoms such as palpitations and chest tightness instead of respiratory symptoms
        • typical presenting symptoms of COVID-19 such as fatigue, dyspnea, and cough are similar to clinical presentation of preexisting cardiovascular disease such as decompensated heart failure or arrhythmias
      • myocardial injury may be defined as elevated cardiac troponin levels, elevated cardiac biomarker levels to > 99th percentile of upper reference limit, or elevated cardiac biomarker levels plus electrocardiographic and echocardiographic abnormalities
      • dyspnea with or without chest pain, elevated cardiac biomarkers, electrocardiography abnormalities, and reduced cardiac function may be common in hospitalized patients with COVID-19-related myocarditis
      • American College of Cardiology guidance: perform echocardiography in patients who experience heart failure, arrhythmia, electrocardiography changes, or cardiomegaly
    • management considerations for patients with COVID-19-related acute cardiac complications
    • considerations for use of renin-angiotensin-aldosterone system (RAAS) antagonists
      • theoretical concerns on use of RAAS antagonists in COVID-19 have been raised, generally related to angiotensin-converting enzyme-2 (ACE2) functioning as a co-receptor for entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) and limited evidence of upregulation of ACE2 by RAAS antagonists
      • guidance from professional organizations, including the American College of Cardiology and European Society of Cardiology, agree on continuing RAAS antagonists in patients without COVID-19 who have a current prescription, and to not start or discontinue RAAS antagonists in patients with SARS-CoV-2 infection
    • considerations for drugs potentially used for treatment of COVID-19
      • hydroxychloroquine and azithromycin may both provoke proarrhythmia and effect of combination therapy on QT or arrhythmia has not been studied
      • to minimize arrhythmia risk when using hydroxychloroquine and/or azithromycin, perform ECG/QT interval monitoring, correct electrolyte imbalances (hypokalemia and/or hypomagnesemia), and avoid other QTc prolonging agents if possible
      • precautions in specific patient populations may include
        • if known congenital long QT syndrome, avoiding QT-prolonging medications or careful ECG monitoring may be required
        • if severe renal insufficiency present, reduce dose of hydroxychloroquine
        • if currently using QT-prolonging medication, consider ECG monitoring
        • if electrolyte abnormalities exist, imbalances should be corrected and patients should be monitored regularly
      • if evidence of QT prolongation and/or arrhythmic toxicity during treatment
        • consider temporarily stopping use of class III antiarrhythmic medication and using alternative
        • aggressive correction of electrolyte imbalance may mitigate toxicity
    • see COVID-19 and Cardiovascular Disease Patients for details

Chronic Kidney Disease (CKD) and End-stage Renal Disease (ESRD)

  • patients with existing conditions can be more susceptible to COVID-19 and are likely to experience more severe illness, including patients with CKD, patients on chronic dialysis, and those living with a kidney transplant
  • kidney abnormalities associated with increased in-hospital mortality in patients with COVID-19; kidney abnormalities may include proteinuria, hematuria, elevated serum creatinine, elevated blood urea nitrogen, and estimated glomerular filtration rate (GFR) < 60 mL/minute/1.73 m2
  • for patients with CKD
    • CKD appears to be associated with severe COVID-19
    • advise patients to remain on medications at prescribed doses, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) unless indicated otherwise by treating clinician
    • management of patients with COVID-19 and with CKD treated with immunosuppressive therapy may depend on severity of COVID-19
  • for patients on chronic dialysis
    • management of patients on dialysis should be carried by strict adherence to protocols to minimize spread of infection
    • strategies to mitigate risk and spread of COVID-19 infection in dialysis facilities include
      • following policies and protocols that should already be in place to reduce spread of contagious respiratory pathogens
      • early recognition and isolation of patients requiring dialysis if presenting with signs and symptoms consistent with respiratory infection; patients with symptoms must inform facility personnel prior to arrival and wear face mask at all times
      • ensuring maintenance of distance (≥ 6 feet or ≥ 2 meters) between infected patients and those who are not infected at all times, including in waiting rooms and in treatment areas
      • providing updated information on precautionary measures and tools (for example, alcohol-based hand-sanitizers and personal protection equipment) to protect both patient and personnel
      • use of isolation rooms, if available, for treatment
      • cohorting patients with suspected or confirmed COVID-19 infection and personnel caring for them together in 1 section of the unit or on same shift
      • routine cleaning, disinfection, or disposal (if appropriate) of all surfaces, materials, and equipment, especially if they have come in close contact (within 6 feet or 2 meters) of infected patient
    • patients on dialysis who have a family member or caregiver who is in quarantine as part of precautionary isolation (14 days), but not presenting with symptoms of infection, may undergo dialysis during quarantine period
    • once family member or caregiver has been confirmed as having COVID-19 infection, patient must be upgraded and treated in accordance with those who are suspected of having COVID-19 infection
  • for patients with kidney transplant
    • kidney transplant recipients and patients using immunosuppressive therapy can be more susceptible to COVID-19 and are likely to experience more severe illness, and should take measures to prevent infection
    • for management of kidney transplant patients with COVID-19 hospitalized with pneumonitis, might consider replacement therapy with methylprednisolone 16 mg and concurrent withdrawal of mycophenolate mofetil and azathioprine, calcineurin inhibitors, and mTOR inhibitors
  • see also COVID-19 and Patients with Chronic Kidney Disease (CKD) and End-stage Renal Disease (ESRD) for details

Endocrine Conditions

Diabetes

  • statements and recommendations from professional organizations
    • European Society of Endocrinology
      • preventing infection by COVID-19 in people with diabetes
        • persons with diabetes should strictly adhere to social distancing and other preventive measures and adopt them also within their homes in order to avoid being in contact with their relatives
        • people with diabetes should try to plan ahead of time what to do if they get sick
        • people with diabetes should maintain good glycemic control to reduce the risk of infection and possibly decrease the severity of the disease if they become infected
        • routine appointments in person are not recommended for people with diabetes
        • phone calls, video calls, and emails are suggested as the main way to keep in touch with healthcare providers
        • patients should make sure there is an adequate amount of medications and supplies for monitoring blood glucose during the period of home confinement
      • managing diabetes in persons infected with COVID-19
        • in case of possible symptoms of COVID-19 infection, patients should contact the healthcare provider team by telephone, email, or videoconference in order to seek advice concerning the measures to avoid risk of deterioration of diabetes control and the appropriate treatment setting
        • when infected with COVID-19 there may be a deterioration of glycemic control similar to other infections
        • “sick day rules” should be used to overcome potential diabetes decompensation
      • PubMed32279224EndocrineEndocrine202004016812-52Reference - Endocrine 2020 Apr;68(1):2full-text
    • International Diabetes Federation Europe recommendations on sick day management
      • COVID-19 infection is likely to have an effect on blood glucose levels
      • people living with diabetes, their carers, and parents of children living with diabetes should work with their healthcare team to have an illness plan in place
      • illness plan should include
        • target blood glucose goals during an illness, which may be different from under normal conditions
        • how to adjust their medicines (especially insulin)
        • when to contact their healthcare team (such as elevated blood glucose for > 24 hours, vomiting repeatedly, or symptoms of diabetic ketoacidosis)
        • how often to check their blood glucose and ketone levels
      • advice for all persons with diabetes who become sick
        • take diabetes medication as usual unless otherwise directed by their healthcare team
        • insulin treatment should never be stopped but may need to be adjusted
        • test blood glucose every four hours, and keep track of the results
        • avoid dehydration by drinking extra (calorie-free) fluid, and try to eat normally
        • weigh themselves every day as weight loss may be a sign of high blood glucose and dehydration
        • check temperature every morning and evening
      • additional advice for persons with type 1 diabetes
        • insulin treatment should never be stopped
        • insulin dose may need to be increased and additional doses of fast-acting insulin may be needed to bring down the blood glucose levels
        • blood glucose levels should be checked at least every four hours
        • aim for blood glucose levels between 110-180 mg/dL (6-10 mmol/L)
      • International Diabetes Federation Europe Sick Day Rules for People with Diabetes (IDF Europe PDF accessed 2020 Apr 29)
  • the mechanism by which diabetes predisposes to more severe disease in patients with diabetes is poorly delineated, but pathophysiologic explanations that have been proposed include
    • infection of hepatocytes and pancreatic beta-cells by SARS-CoV-2, which could worsen hyperglycemia at least during the acute infection
    • higher levels of chronic inflammation in patients with diabetes, which might facilitate the cytokine storm
      • interleukin-6 more elevated in COVID-19 infected patients with diabetes than in those without
      • other markers of inflammation more elevated in COVID-19 infected patients with diabetes include fibrinogen, C-reactive protein, and D-dimer
    • PubMed32233018Diabetes/metabolism research and reviewsDiabetes Metab Res Rev20200331e33213321e33213321Reference - Diabetes Metab Res Rev 2020 Mar 31 early online
  • Study Summary
    diabetes appears to be a risk factor of worse outcomes in patients with COVID-19
    Details
    studySummary
    • Cohort Study based on retrospective cohort study
    • 1,099 patients from China with COVID-19 were assessed for their clinical characteristics and outcomes
    • diabetes identified as a comorbidity in
      • 5.7% of mild cases
      • 16.2% of severe cases
    • additional risk factors overrepresented by a factor of at least two in patients from China with severe disease which are often comorbid with diabetes include
      • older age
      • hypertension
      • chronic renal disease
    • PubMed32109013The New England journal of medicineN Engl J Med20200430382181708-17201708Reference - N Engl J Med 2020 Apr 30;382(18):1708full-text
  • Study Summary
    diabetes without known complications may not increase mortality in patients with COVID-19
    Details
    studySummary
    • Cohort Study based on cohort study without adjustments for multiple comparisons
    • 174 consecutive hospitalized patients from Wuhan, China with COVID-19 were analyzed based on presence or absence of diabetes mellitus
      • 37 patients had diabetes mellitus, 137 did not
      • 24 patients had diabetes mellitus without significant comorbidities
      • 26 patients without diabetes, did not have other significant comorbidities
    • on admission to the hospital, 29% of patients with diabetes without other comorbidities were on insulin and 12.5% developed diabetic ketoacidosis
      • all patients on insulin prior to admission required increases in their insulin dose during hospitalization
      • 52.9% of those not on insulin before admission were started on insulin during hospitalization
    • compared to patients without diabetes, patients with diabetes had
      • more cardiovascular disease (32.4% vs 14.6%, p= 0.013)
      • less fever (59.5% vs 83.2%, p= 0.002)
      • no significant differences in gender, age, or mortality
    • among patients without comorbidities, patients with diabetes
      • were significantly older than those without (median age 61 years vs. 32 years, p < 0.01)
      • had higher mortality than those without diabetes (16.5% vs 0%, p = 0.03)
    • PubMed32233013Diabetes/metabolism research and reviewsDiabetes Metab Res Rev20200331e3319e3319Reference - Diabetes Metab Res Rev 2020 Mar 31 early online
    • DynaMed Commentary

      The authors focus on the 24 patients without comorbidities, but the difference in age between them and the controls fatally biases any conclusion. In addition, as many patients with diabetes will have comorbidities, looking only at those without is less useful when generalizing the results to other clinical settings.

  • use of renin–angiotensin–aldosterone system (RAAS) inhibitors in patients with COVID-19
    • RAAS inhibitors include both angiotensin-converting enzyme (ACE) inhibitors and angiotensin recptor blockers
    • SARS-CoV-2 appears to gain initial entry into cells through ACE2 receptors and subsequently down-regulate ACE2 expression
    • concerns raised that RAAS inhibitors might increase risks associated with COVID-19 infections, but it has also been proposed that RAAS inhibitors might be protective in COVID-19 infections
    • most data is preclinical and actual effects of continuing or stopping RAAS inhibitors is unknown
    • abruptly stopping RAAS inhibitors in high-risk patients may result in significant adverse health outcomes
    • multiple specialty societies all endorse continuing RAAS inhibitors in clinically stable patients including
      • American College of Physicians
      • American Heart Association
      • American College of Cardiology
      • European Society of Cardiology
      • British Cardiovascular Society
      • High Blood Pressure Research Council of Australia
      • Hypertension Canada
    • PubMed32227760The New England journal of medicineN Engl J Med20200330Reference - N Engl J Med 2020 Apr 23;382(17):1653full-text

Thyroid Disorders

  • British Thyroid Association/Society for Endocrinology (BTA/SFE) statement regarding issues specific to thyroid dysfunction during the COVID-19 pandemic
    • there is no specific information on how COVID-19 affects individuals with thyroid disease
    • risk for developing COVID-19 extrapolated from risks for viral infections in general
      • thyroid disease has not been associated with increased risk of viral infections in general
      • no evidence that recent treatment with radioiodine or thyroid surgery for benign thyroid disease increases risk of viral infections
      • no evidence linking poorly controlled thyroid disease to increased risk of viral infections in general
      • while there is no evidence linking poorly controlled thyroid disease to increased risk of viral infections in general, it is possible that uncontrolled thyroid disease (especially thyrotoxicosis) may increase risk of complications from any infection
    • medications which suppress the immune system, such as chronic corticosteroids or rituximab (which can be used for treating thyroid-related ophthalmopathy), can dramatically increase risk associated with COVID-19 infection; patients need to self-isolate during pandemic
    • for patients on antithyroid drugs
      • antithyroid drugs are not associated with increased risk of infection, unless they result in agranulocytosis
      • for patients on antithyroid drugs with any symptoms suggestive of neutropenia (such as sore throat, mouth ulcers, fever, or flu-like illness), STOP the antithyroid drugs until an urgent complete blood count can be performed to measure white cell count and differential
        • for patient infected with COVID-19, antithyroid drugs may be continued unless absolute neutrophil count is ≤ 1.0 × 109/L
        • if blood tests cannot be obtained, have patients stay off medications and restart one week later if symptoms have resolved
    • for patients being treated for thyrotoxicosis
      • management should continue to be guided by results of thyroid function tests
      • if unable to monitor with blood tests because of COVID-19, consider ‘block and replace’ by giving antithyroid drugs and levothyroxine simultaneously
      • suggested regimen can be found at Society for Endocrinology
    • Reference - BTA/SFE 2020 Mar PDF
  • BTA/SFE advice for patients with thyroid cancer during the COVID-19 pandemic
    • no evidence treatment with radioiodine or thyroid surgery for thyroid cancer increases risk of viral infections
    • treatment with suppressive doses of levothyroxine should be continued at current dose as this does not increase the risk of COVID-19 infection
    • clinical scenarios associated with increased risk for COVID-19 include
      • treatment with chemotherapy
      • treatment with multikinase inhibitors (such as lenvatinib or sorafenib)
      • history of treatment with external beam radiation to the neck
    • Reference - BTA/SFE 2020 Mar PDF

HIV Infection

Recommendations from Professional Organizations

  • United States Department of Health and Human Services (DHHS) interim recommendations for COVID-19 in persons with HIV
    • COVID-19 disease course in persons with HIV
      • limited information available
        • prior to availability of effective antiretroviral therapy (ART), advanced HIV infection (CD4 T-cell count < 200 cells/mcL) associated with increased risk for complications of other respiratory infections
        • unknown if HIV is associated with increased severity of COVID-19
      • persons with HIV may have other characteristics associated with increased COVID-19 severity, such as
        • other comorbidities, such as cardiovascular disease, diabetes mellitus, or lung disease
        • history of chronic smoking
    • general management
      • persons with HIV should follow standard recommendations to prevent COVID-19, including social distancing and hand hygiene
      • additional caution reasonable in persons with HIV, especially in persons with advanced or poorly controlled HIV
      • ensure influenza and pneumococcal vaccinations current
    • antiretroviral therapy
      • maintain at least 30-day supply (preferably 90-day supply) of ART and other medications
      • discuss with pharmacists and/or other healthcare providers about switching to mail order delivery of medications
      • consider delaying planned switch in regimen until close follow-up and monitoring possible
      • although lopinavir/ritonavir has been used as off-label treatment for COVID-19 and is currently being evaluated in clinical trials, patients without lopinavir/ritonavir as part of ART regimen should not have regimens switched to include lopinavir/ritonavir
    • clinical or laboratory monitoring related to HIV care
      • persons with HIV and their healthcare providers should weigh risks and benefits of attending in-person HIV-related clinic appointments, taking into consideration
        • extent of local COVID-19 transmission
        • health needs addressed during appointment
        • HIV status and overall health
      • face-to-face encounters may be replaced by telephone or virtual visits for routine or non-urgent care
      • persons with suppressed viral load and stable health should postpone routine medical visits to extent possible
    • avoid treatment interruptions for persons with HIV enrolled in opioid treatment programs
    • pregnant individuals with HIV
      • limited information available on disease course
      • immunologic and physical changes associated with pregnancy generally increase risk of viral respiratory infection
      • although risk of severe disease with other coronavirus infections is greater among pregnant individuals compared to general population, no evidence that pregnancy is associated with increased susceptibility to COVID-19 or risk of severe disease
      • adverse pregnancy outcomes have been reported, including fetal distress and preterm delivery
      • no evidence of vertical transmission, although ≥ 1 case of neonatal COVID-19 described
      • see also COVID-19 and Pregnant Patients
    • children with HIV
      • COVID-19 appears less severe in children, although subpopulations of children may be at increased risk of severe disease
      • younger age, underlying pulmonary pathology, and immunocompromise associated with more severe outcomes in children with non-COVID-19 coronavirus infection
      • infants and children should be current with all immunizations, including influenza and pneumococcal vaccinations
      • see also COVID-19 and Pediatric Patients
    • persons with HIV in self-isolation or quarantine due to SARS-CoV-2 exposure
      • healthcare workers should
        • ensure patients have adequate supplies of all medications and expedite refills if necessary
        • devise plan to evaluate patients with COVID-19 if they develop symptoms, including possible transfer to healthcare facility
      • persons with HIV should
        • contact healthcare provider to report self-isolation or quarantine
        • inform healthcare providers about amount of antiretroviral medication or other essential medication on hand
    • persons with HIV and fever or respiratory symptoms seeking evaluation and care
      • healthcare workers caring for patient should follow recommendations of United States Centers for Disease Control and Prevention (CDC), as well as state and local health departments
      • persons with HIV should
        • follow CDC recommendations regarding symptoms such as fever, cough, or shortness of breath
        • call healthcare provider for medical advice if fever and other symptoms (cough, difficulty breathing) develop
        • call clinic prior to presenting to care providers
        • use respiratory and hand hygiene, and request mask upon arrival to care facility
        • if unable to call in advance, alert staff immediately upon arrival of symptoms so measures can be taken to reduce risk of COVID-19 transmission
      • see also COVID-19 (Novel Coronavirus)
    • persons with HIV who develop COVID-19
      • recommendations for person with HIV if hospitalization not necessary
        • manage symptoms at home with supportive care
        • maintain communication with healthcare providers and report any symptom progression
        • continue ART and any additional medications as prescribed
      • recommendations for person with HIV who is hospitalized
        • continue ART, administering from home supplies if ART drugs not on hospital formulary
        • avoid antiretroviral drug substitutions
        • if drug substitutions necessary, follow United States Health and Human Services (DHHS) guidelines for caring for person with HIV in disaster areas (guideline can be found at AIDSinfo 2018 Sep 14)
        • arrange for hospital provider to continue administration of ibalizumab IV infusions every 2 weeks for patients receiving ibalizumab
        • make arrangements with investigational study team to continue medication for patients taking investigational antiretroviral medication
        • for patients requiring tube feeding
          • some antiretroviral medications available in liquid formulations and some (but not all) pills may be crushed
          • consult with HIV specialist or pharmacist to assess best way to continue ART regimen
      • if investigational or off-label treatment for COVID-19 used
        • assess potential for drug-drug interactions between therapy and ART regimen
        • do not exclude persons with HIV from investigational trials
    • other guidance for clinicians
      • ask providers to waive drug-supply quantity restrictions if applicable
      • make every attempt to assess patient need for additional social assistance and connect patients with available resources
      • assess and address mental health and substance abuse issues which may be exacerbated by social distancing and isolation, with additional consultation as needed (preferably virtual)
      • consider telehealth options, including phone calls, for ill patients
    • Reference - AIDSinfo 2020 Apr 21

Guidelines and Resources

Neurological Conditions

Multiple Sclerosis (MS)

Recommendations and Advice Regarding Disease MS Treatment

  • patients on immunosuppressive therapies (such as for MS) may be at increased risk of infection and complications (Neurology 2020 Mar 30 early online)
  • general advice for patients with MS during the COVID-19 pandemic includes
  • special editorial (in Neurology 2020 Apr) on treating MS and neuromyelitis optica spectrum disorder during the COVID-19 pandemic
    • MS (particularly if treated with second-generation DMTs) associated with increased risk of infection in general; risk of COVID-19 specifically not known but presumed to be increased as well
    • consider altering management strategies to reduce nonessential visits
      • home delivery of medications
      • delaying follow-up imaging and laboratory testing in stable patients
      • reduced frequency infusion schedule
    • general advice for persons with MS
      • follow COVID-19-related advice for general population, such as frequent hand washing and social distancing
      • be aware of symptoms of COVID-19 (usually fever, cough, and shortness of breath)
      • do not change MS treatment without first discussing with neurologist
    • if suspected acute MS relapse
      • an acute infection might result in transient exacerbation ("pseudo-relapse"); consider screening for symptoms of active COVID-19 infection before considering corticosteroids
      • consider having a higher threshold for starting corticosteroid treatment due to increased risk of infection
      • if starting corticosteroids, consider high-dose oral regimen to reduce need for inpatient visit
    • considerations for DMTs depend on their immunosuppressive effects
      • DMTs with immunosuppressive effects potentially increase risk of infections in general, but specific risk of COVID-19 infection is not known
      • benefits of continued treatment with DMTs likely outweigh risks of COVID-19 infection for most patients
      • for adults > 60 years old, treatment decisions must be individualized - DMTs may be less effective and comorbidities may increase severity of COVID-19 infection
      • for persons with progressive MS, DMTs may be less effective
      • no special considerations for children or pregnant women
    • considerations for initiating DMTs depends on their immunosuppressive effects
      • initiate treatment as usual with DMTs with no-to-low risk of systemic immunosuppression
        • interferon-beta
        • glatiramer acetate
        • teriflunomide
        • dimethyl fumarate
        • natalizumab
      • consider delaying initiating treatment (or choosing a low-risk DMT instead) with DMTs with moderate risk of systemic immunosuppression
        • S1P modulators - fingolimod, siponimod, and ozanimod
        • anti-CD20 agents - ocrelizumab and rituximab
      • do not initiate treatment (or choose a low-risk DMT instead) with DMTs with high risk of systemic immunosuppression
        • cladribine
        • alemtuzumab
        • autologous hematopoietic stem cell transplant
    • considerations for continuing with DMTs already initiated depends on their risk of immunosuppressive effects
      • continue treatment as usual with interferon-beta and glatiramer acetate (very low-to-no risk of systemic immunosuppression)
      • consider discontinuing treatment under certain conditions, or extending interval dosing, with DMTs with low-to-moderate risk of systemic immunosuppression
        • teriflunomide - consider discontinuation if neutrophil count ≤ 1,000 cells/mm3
        • dimethyl fumarate - consider discontinuation if lymphocyte count ≤ 500-800 cells/mm3
        • natalizumab - consider extended interval dosing
        • S1P modulators (fingolimod, siponimod, and ozanimod) - consider discontinuation if lymphocyte count ≤ 200-300 cells/mm3
        • anti-CD20 agents (ocrelizumab and rituximab) - consider extended interval dosing guided by CD19 lymphocyte counts and periodic assessments
      • delay further courses of treatment (based on risks, benefits, and periodic assessments) with DMTs with high risk of systemic immunosuppression
        • cladribine
        • alemtuzumab
    • for persons with MS who have COVID-19 infection
      • if mild COVID-19 infection
        • consider continuing with immunotherapy with caution
        • have lower threshold for stopping immunotherapy in patients
          • taking medications with greater immunosuppressive effects
          • at greater risk of more severe COVID-19 symptoms, such as, if older age or more comorbidities
      • if severe COVID-19 infection, consider discontinuing immunotherapy, with possible resumption after 4 weeks or after symptoms have resolved (but be aware of potential rebound MS activity with S1P modulators and natalizumab)
      • if hospitalized, alert physicians of importance of fever management for patients with MS
    • Reference - Neurology 2020 Apr 2 early online
  • Association of British Neurologists (ABN) recommendations on disease-modifying therapies for MS
    • it is safe to start or continue
      • interferon beta 1a and 1b
      • glatiramer
      • teriflunomide
      • dimethyl fumarate
      • natalizumab
    • fingolimod and ocrelizumab have moderately increased risk of acquiring COVID-19 infection
      • fingolimod
        • for patients already taking fingolimod, risk of rebound MS probably outweighs risk of COVID-19 infection
        • if disease breakthrough on first-line medication, fingolimod may be advantageous over ocrelizumab because it can be stopped if COVID-19 infection
      • ocrelizumab
        • may be an option if high-efficacy medication needed and patient not eligible for natalizumab
        • ocrelizumab associated with persistently increased risk of infection
        • for patients already taking ocrelizumab, delay further infusions until risk of COVD-19 is clarified or passed (ocrelizumab may remain effective for > 6 months)
    • alemtuzumab and cladribine have higher risk of acquiring COVID-19 infection
      • do not start during COVID-19 epidemic; consider natalizumab or ocrelizumab instead
      • for patients who already had 1st course of alemtuzumab or cladribine, delay 2nd course until COVID-19 risk has passed
        • for alemtuzumab, duration between 1st and 2nd course of 18 months is safe without increasing risk of MS activity return
        • for cladribine, safety of duration up to 18 months is not known
      • if 3rd course of alemtuzumab is being considered, either delay course or use other DMT until COVID-19 risk has passed
    • postpone autologous hematopoietic stem cell transplantation until COVID-19 risk has passed; it has highest risk of acquiring COVID-19 infection
    • for MS patients with COVID-19 infection
      • if mild symptoms, it is not necessary to stop DMT
      • if severe symptoms, pause all injectable and oral medications, and delay infusions
        • optimal timing of resumption is unclear
        • fingolimod and natalizumab associated with risk of rebound disease after 2-4 months
      • delay stem cell transplant for 3 months
    • Reference - ABN guidance on use of DMTs April 2020 PDF (also includes patient information)
  • estimated relative risks of acquiring COVID-19 infection with disease modifying therapies (DMTs) (reported in commentary from Mult Scler Relat Disord 2020 Apr)PubMed32334820Multiple sclerosis and related disordersMult Scler Relat Disord2020040139102073102073
    • DMTs with very low additional risk
      • interferon-beta
      • glatiramer acetate
      • teriflunomide
    • DMTs with low additional risk
      • dimethyl fumarate
      • natalizumab
    • DMTs with intermediate additional risk
      • S1P modulators (such as fingolimod, siponimod, ozanimod, and ponesimod)
      • anti-CD20 agents (ocrelizumab, ofatumumab, rituximab, and ublituximab)
      • cladribine
    • DMTs with high additional risk
      • mitoxantrone
      • alemtuzumab
      • hemopoietic stem cell transplant
    • Reference - Mult Scler Relat Disord 2020 Apr;39:102073full-text
  • reported infection risks of specific disease modifying therapies
    • interferon beta-1a and beta-1b - no increased risk of infection
    • glatiramer acetate - no increased risk of infection
    • dimethyl fumarate - potential risk of progressive multifocal leukoencephalopathy (PML)
    • teriflunomide - potential reactivation of tuberculosis
    • S1P modulators - potential increased risks of certain opportunstic infections (PML, Cryptococcus, varicella zoster, and human papillomavirus [HPV]) and slight increased risk of lower respiratory infections
    • cladribine - slight increased risk of herpes infections with grade 3 or 4 lymphopenia
    • natalizumab - potential risk of PML
    • anti-CD20 monoclonal antibodies - potential increased risk of upper respiratory infections, reactivation of chronic hepatitis B
    • alemtuzumab - reactivated herpes simplex and varicella zoster virus infections, listeria, and HPV
    • Reference - Neurol Neuroimmunol Neuroinflamm 2020 Jul;7(4) early online

Evidence in Patients with MS

  • Study Summary
    mild COVID-19 severity reported in 64% of patients and recovered or recovering status in 100% of patients taking ocrelizumab for MS who had COVID-19 infection, but evidence is limited
    Details
    studySummary
    • Cohort Studybased on retrospective cohort study
    • 100 adults (mean age about 42 years, about 63% women) taking ocrelizumab for MS who had confirmed (in 74) or suspected (26) COVID-19 infection were assessed via voluntary Roche/Genentech safety database adverse event reports (pharmacovigilance study)
    • hospitalization in 26 patients, all with confirmed COVID-19 infection
    • COVID-19 severity (in 77 patients with available data)
      • mild in 64%
      • severe in 30%
      • critical in 6%
    • recovered or recovering status in 100% of 64 patients with available date
    • PubMed32426207Multiple sclerosis and related disordersMult Scler Relat Disord20200516102192102192Reference - Mult Scler Relat Disord 2020 May 16;:102192full-text
    • DynaMed Commentary

      The authors note that potential sources of bias in this pharmacovigilance study are that adverse event reporting is voluntary, reported information may be limited and incomplete, and follow-up data may be difficult to obtain. Also, reporting during the COVID-19 pandemic may exacerbate these issues due to increased strain on healthcare systems.

  • Study Summary
    death reported in 2 of 8 adults with MS and COVID-19 infection, both with severe MS-related disability, severe COVID-19-related symptoms, and comorbidities
    Details
    studySummary
    • Case Seriesbased on case series
    • 8 adults (mean age 51 years, 75% women) with MS who had COVID-19 infection were assessed
      • relapsing-remitting MS in 5 patients, secondary progressive MS in 3 patients
      • disease-modifying therapy included dimethyl fumarate (in 2 patients), fingolimod (2), interferon beta (1), glatiramer acetate (1), teriflunomide (1); 1 patient did not have disease-modifying therapy
      • no recent relapse or corticosteroid treatment
    • COVID-19 symptoms lasted 6-28 days, with hospitalization in 3 patients (including 1 primarily for observation)
    • full recovery in 5 patients; recovery in progress in 1 patient
    • death in 2 patients (ages were 55 and 74 years)
      • 1 taking teriflunomide and 1 not on disease-modifying therapy
      • both had
        • secondary progressive MS with severe disability
        • severe COVID-19 symptoms (hypoxia, dyspnea, fever, and altered mental status)
        • comorbidities (1 with myotonic dystrophy and 1 with cardiovascular, pulmonary, and metabolic comorbidities)
    • PubMed32457226Neurology(R) neuroimmunology & neuroinflammationNeurol Neuroimmunol Neuroinflamm2020052675Reference - Neurol Neuroimmunol Neuroinflamm 2020 May 26;7(5):e783
  • case reports of patients taking disease modifying therapies for MS who acquired COVID-19 infection
    • PubMed32464586Multiple sclerosis and related disordersMult Scler Relat Disord2020052343102222102222ocrelizumab - recovered from COVID-19 infection without need for hospitalization (Mult Scler Relat Disord 2020 May 23;43:102222)
    • PubMed32463329Multiple sclerosis (Houndmills, Basingstoke, England)Mult Scler2020052813524585209264591352458520926459alemtuzumab - mild uncomplicated COVID-19 infection (Mult Scler 2020 May 28;:1352458520926459)

Links to Additional Resources

Patients Taking Immunotherapy

  • see Multiple Sclerosis (MS) section for recommendations for patients with MS
  • immunosuppressive therapies have the potential for increasing the risks of COVID-19 infection and severe complications, but precise risks are not known
  • Italian Society of Neurology (SIN), the Italian Society of Clinical Neurophysiology (SINC) and the Italian Peripheral Nervous System Association (ASNP) task force recommendations on managing immune-mediated neuropathies during the COVID-19 outbreak
    • individualize the following recommendations and statements according to neuropathy severity and progression, local healthcare strategic planning, and COVID-19 infection risk
    • currently no evidence that
      • immune-mediated neuropathy associated with increased risk of COVID-19 infection
      • COVID-19 infection associated with increased risk of immune-mediated neuropathy
    • avoid or postpone outpatient visits and treatment if possible to reduce risk of acquiring COVID-19 infection
      • use remote visits (such as with telemedicine or e-consultation) if possible
      • evaluate feasibility of "virtual approach" according to individual patient and specific circumstances
    • considerations for starting therapy for immune-mediated neuropathy
      • do not start immunosuppressive/immunomodulatory therapy unless clinically necessary
        • such therapies have the potential to suppressive immune system
        • ancillary procedures, such as blood tests or visiting hospital, may be required and these may increase risk of acquiring COVID-19 infection
      • for immunoglobulin therapies that require visits to infusion center/hospital, evaluate risk of frequent visits
      • corticosteroid therapy if indicated may be preferred over immunoglobulin therapy even though it may reduce immune response
    • for patients taking immunosuppresive therapy
      • immunosuppressive therapy may increase susceptibility to infections, including COVID-19
      • advise patient that reducing or stopping current immunosuppressive therapy may increase of disease activity and/or exacerbate neuropathy
      • continue with first-line (such as coricosteroids) and second- or third-line medications (such as azathioprine, methotrexate, cyclosporine, mycophenolate mofetil, or cyclophosphamide) medications, paying high attention to personal protective equipment
      • advise patient to
        • follow local laws for contact during the COVID-19 pandemic (Ministry of Health and National and Local laws in Italy)
        • take additional steps to reduce risk of COVID-19 infection
          • avoid leaving the house for any reason including shopping
          • work from home whenever this is possible
          • go to hospital only in exceptional cases, and not before contacting the treating neurologist
          • have family members to pick up the treatment provided by the pharmacy or hospital
      • if pulsed treatment with intravenous corticosteroids, patients should continue therapy at home if possible; if not, consider oral or intramuscular injection at same dose or another corticosteroid at equivalent dose
      • if planned inpatient infusion therapy with rituximab or cyclophosphamide, evaluate the risk-benefit ratio of postponing the treatment
      • if maintenance rituximab therapy, consider delaying infusion beyond 6 months if the CD19 and CD20 lymphocytes are suppressed
      • if frequent blood monitoring required for immunosuppressive therapy, consider reducing the frequency of blood monitoring or performing home blood sampling
    • for patients taking immunoglobulin therapy or having plasmapheresis
      • immunoglobulin therapies and plasmapheresis do no themselves increase risk of acquiring COVID-19 infection
      • however, intravenous immunoglobulin (IVIG) therapy and plasmapheresis both require requires visits to infusion center/hospital, which increase risk of acquiring COVID-19 infection
      • if planned IVIG, consider subcutaneous immunoglobulin instead to avoid visiting infusion center
      • no evidence that immunoglobulin therapies reduce risk of acquiring COVID-19 infection
    • for monitoring immune-mediated neuropathy
      • do not request clinical and instrumental evaluations to monitor the disease course (such as blood tests, electroneurography/myography, nerve ultrasound, or imaging) unless considered essential by the neurologist
      • monitor and assess patients by telephone call or telemedicine to reduce the risk of needing to hospitalize patient, which would increase the risk of COVID-19 infection
    • for patients with immune-mediated neuropathy and COVID-19 infection
      • do not start immunosuppressive therapy during positivity phase of COVID-19 infection or during quarantine
      • currently no evidence to support discontinuation of immunosuppressive therapy
        • evidence with previous coronavirus epidemics suggests that immunocompromised patients are not exposed to more aggressive lung disease
        • however, consider postponing rituximab or cyclophosphamide during positivity phase for COVID-19 infection or during quarantine
        • decision to reduce or stop therapy should be made with treating neurologist
        • do not stop corticosteroid therapy abruptly; rather, progressively reduce until suspension (if suspending)
        • no current contraindication for immunoglobulin therapy; however, note that both IVIG and COVID-19 infection are associated with increased risk of venous thrombosis
    • considerations for neurophysiological testing
      • only request neurophysiological testing if it might substantially change management; otherwise postpone testing
      • healthcare staff should use
        • standard individual protection devices if patient not suspected to have COVID-19 infection
        • personal protective equipment including appropriate masks, face shields, gowns and gloves if patient suspected to have COVID-19 infection
      • provide surgery masks and gloves to all patients
      • use disposable materials
      • pay special attention to cleaning equipment
    • Reference - Neurol Sci 2020 May 4 early onlinefull-text
  • European Academy of Neurology (EAN) statements and recommendations on immunotherapy for patients with neuroimmunological disorders during the COVID-19 pandemic (2020 April 1)
    • any therapy decisions should be individualized and made collaboratively between patient and healthcare provider
    • currently no evidence on how COVID-19 affects people with neuroimmunological disorders such as MS, myasthenia gravis, central nervous system vasculitis, or autoimmune encephalitis
      • immunomodulatory therapies used to treat these disorders have the potential to increase the risk of COVID-19 and other infections; precise risks are not known
      • risk of disease exacerbation by stopping immunotherapy may outweigh potential risks of COVID-19 infection or increased severity
      • associated respiratory muscle weakness, such as with myasthenia gravis, has the potential to increase risk and severity of COVID-19 infection
    • be extra vigilant in following general measures to reduce risk of COVID-19 infection, including washing hands frequently, avoiding public gatherings and crowds, using remote communications where possible, and using protective masks and hand sanitizers if traveling is absolutely necessary
    • if any acute signs of infection, do not start or continue immunotherapy; immune depleting agents in particular should be delayed until symptoms resolve
    • considerations for specific therapies or classes of therapies
      • noncontinuous treatments - consider not making short-term changes
      • infusion therapies that require travel to infusion centers - strongly consider basing decision on starting/continuing with therapy, or to switching home infusion, on regional incidence of COVID-19 infection and risk-benefit ratio of therapy for individual patient
      • fingolimod and siponimod (sphingosin-1-phosphate-receptor-modulators)
        • may be associated with increased risk of respiratory infection, but stopping them may elicit disease return in patients with MS (including rebound activity)
        • confine contacts and minimize infection risks
      • therapies with immune depleting properties or primary immune suppressive agents (especially ocrelizumab, rituximab, cladribine, alemtuzumab, and mitoxantrone)
        • may increase risk of infection during first weeks after initiation
        • before starting immune depleting therapy
          • consider risk of immune suppression and increased risk of infection for several weeks after treatment initiation
          • consider delaying treatment until after peak of pandemic in region if disease activity allows, especially for patients with older age or comorbidities, both of which increase risk of infection or severe symptoms
          • consider "bridging therapies" as alternative and discuss in detail with patient
          • if risks associated with not starting immune depleting therapy outweigh risks associated with starting therapy, discuss risks and benefits with patient
        • if ongoing therapy, revise timing retreatment by consultant
      • IV corticosteroid pulse therapies - avoid if no clear indications or justification
      • IV immunoglobulin (IVIG) and plasma exchange
        • no evidence of increased risk of COVID-19 infection
        • base use of IVIG on individual patient needs; avoid indiscriminate use
        • in general, reserve use of IVIG or plasma exchange for patients with acute exacerbations
        • if IVIG or plasma exchange are used for maintenance therapy, continue use but use extra precautions due to need to travel to healthcare facility
      • eculizumab - no evidence of increased risk of COVID-19 infection or severe presentation
    • if frequent blood monitoring is usually required, base decision on monitoring requiring patient to leave their home on individual patient and regional COVID-19 incidence
    • if patient currently enrolled in ongoing clinical trial, base all decisions on patient's best interests
    • make patient aware that there is currently (2020 April 1) no evidence for effective medications for treating COVID-19, that they may potentially worsen some neuroimmunological disease (such as myasthenia gravis), and that they should avoid using them without specific medical approval
    • there is currently no vaccination for COVID-19; for other vaccinations, only consider inactivated vaccines
    • Reference - EAN statements and recommendations on immunotherapy for patients with neuroimmunological disorders during the COVID-19 pandemic (EAN 2020 April 1)
  • Association of British Neurologists (ABN) list of immunosuppressant medications that have the potential for increasing risk of COVID-19 infection
    • immunotherapy-related factors that further increase risk include
      • use of multiple immunotherapies (not necessarily currently)
      • high-dose immunotherapy
      • active disease, particularly very active disease such as new diagnosis and current treatment with IV cyclophosphamide or recent treatment with antibody-depleting therapies
    • immunotherapy medications that have the potential for increasing risk of COVID-19 infection or severe COVID-19 symptoms include
      • prednisolone
        • low risk with prednisolone ≤ 10 mg/day monotherapy
        • medium risk with prednisolone 10-19 mg/day monotherapy or prednisolone ≤ 10 mg/day plus immunosuppressive therapy
        • high risk with prednisolone ≥ 20 mg/day monotherapy or prednisolone 10-19 mg/day plus immunosuppressive therapy
        • patients currently taking prednisolone must not abruptly stop prednisolone; dose increase may actually be required during infection
      • methotrexate (medium risk )
      • leflunomide (medium risk )
      • azathioprine (high risk)
      • 6-mercaptopurine (medium risk )
      • mycophenolate mofetil (medium -to-high risk )
      • myfortic (medium-to-high risk )
      • cyclophosphamide IV or oral (high risk)
      • cyclosporin (medium risk )
      • tacrolimus (medium risk )
      • biologic therapies (probably medium-to-high risk)
        • rituximab, especially if given within last 12 months and/or if low CD19 and CD27 counts
        • anti-tumor necrosis factor (anti-TNF) drugs - etanercept, adalimumab, infliximab, golimumab, and certolizumab
        • tocilizumab IV or subcutaneous injection (SC)
        • abatacept IV or SC
        • JAK inhibitors (such as oral baricitinib and tofacitinib)
        • belimumab IV
        • anakinra SC
        • secukinumab
        • ixekizumab
        • apremilast
        • sarilumab
        • ustekinumab
      • human stem cell transplant
      • apheresis
    • IVIG probably does not increase risk of COVID-19 infection or severe COVID-19 symptoms
    • for patients with COVID-19 infection
      • continue with hydroxychloroquine and sulfasalazine if they are already being used
      • temporarily stop conventional disease-modifying anti-rheumatic drugs (DMARDs) and biologic therapies unless patient has myasthenia gravis or neuromyelitis optica (NMO) spectrum disorder
        • report any cessation to non-neurological healthcare professionals as well
        • if considering cessation in patient with myasthenia gravis or NMO spectrum disorder, first discuss with neurology team
    • Reference - ABN guidance on COVID-19 for people with neurological conditions (ABN 2020 April 6 PDF)

Amyotrophic Lateral Sclerosis (ALS)

  • Association of British Neurologists (ABN) notes that patients with advanced motor neuron disease (such as ALS) are at increased risk of COVID-19 infection, especially if bulbar or respiratory muscle weakness, particularly if forced vital capacity (FVC) is < 60% of predicted value and/or ventilator support is needed (ABN guidance on COVID-19 for people with neurological conditions [ABN 2020 April 6 PDF])
  • European Academy of Neurology (EAN) recommendations on ALS and COVID-19 (2020 April 15)
    • to reduce risk of COVID-19 infection
      • stay at home and avoid visitors (including family), even if they do not have symptoms, to reduce risk of COVD-19 infection
      • increase frequency of hand washing with soap, avoid hand-to-face contact, and clean surfaces with detergent
      • caregivers should sneeze/cough into bent elbow or tissue (which should be discarded immediately) and then wash hands with soap
      • follow local recommendations for wearing masks
    • identify a single principal caregiver who should
      • coordinate patient care
      • always be in same residence as patient in accordance with risk reduction strategies
      • have food and medications delivered
      • follow local recommendations for wearing masks
      • monitor and provide (if necessary, such as if functional and/or cognitive limitations) basic needs of ALS patient such as feeding, hydration, medication administration, respiratory support, mobilization and positioning, hygiene, comfort, and physical and psychological well-being
      • take care of themselves including maintaining physical and psychological well-being
    • identify a secondary caregiver, if possible, who should
      • be available to cover for principal caregiver if necessary (such as if principal caregiver must be quarantined)
      • follow local recommendations for wearing masks
    • if principal and secondary caregiver have unplanned absences, they or the patient (if able) should report the situation to the appropriate ALS health provider - social assistants integrating ALS teams
    • if caregiver is not used (for self-sufficient persons with ALS) or is not available, contact ALS care center (coordinator or social worker who integrates ALS team) to report the situation and arrange support if needed
    • if outpatient care services are used, identify a principal caregiver and secondary caregiver so as to limit external contacts; this team should contact ALS team to report on potential needs and status, and take all necessary precautions to reduce transmission risk
    • if absolute need to travel from home residence, follow all recommendations to reduce risk of infection; these include (but are not limited to)
      • follow local recommendations for wearing masks
      • when arriving home, take off clothes and accessories (such as coats, bags, and gloves) at entrance
      • also leave walking aid/wheelchair (if used) at entrance
      • use alcohol-containing disinfectant gel
      • take off mask (only touch elastic straps)
      • wash hands with alcohol-containing disinfectant products
      • wash clothes with regular laundry detergent at temperatures > 40 degrees C (104 degrees F)
      • disinfect walking aid/wheelchair and surfaces that outside clothes and accessories touched
    • if person with ALS develops fever, nonproductive cough, headache, muscle pain, or dyspnea, in the context of an external contact with someone who could be infected with COVID-19
      • stay calm
      • do not go to hospital or other healthcare center
      • use mask (applies to both patient and caregiver)
      • measure temperature and record symptoms
      • maintain list of medications including dose, route of administration, and time administered
      • contact usual healthcare providers by phone, mail, or internet; if no contact, phone general national healthcare center or COVID-19-specific center if available
      • if noninvasive ventilation used, use face mask without expiratory holes or with holes taped over (to filter expiratory air)
      • if tracheostomy, connect filter and the expiratory piece to tube
      • if assistance needed to remove bronchial secretions, caregiver should use FFP2 mask, goggles, gloves, and gown; immediately discard all biological materials; and then shower
      • caregiver should use mask and goggles
    • if caregiver or family member develops fever, nonproductive cough, headache, muscle pain, or dyspnea, in the context of an external contact with someone who could be infected with COVID-19
      • stay calm
      • do not go to hospital or other healthcare center
      • use mask (applies to both patient and caregiver)
      • record symptoms of caregiver and person with ALS
      • maintain list of medications including dose, route of administration, and time administered
      • contact secondary caregiver so they can substitute care if needed
      • contact usual healthcare providers of person with ALS
      • phone general national healthcare center or COVID-19-specific center if available
    • if respiratory decompensation in patient under home ventilatory support or initial ALS-related respiratory symptoms
      • contact usual healthcare providers of person with ALS
      • if needed, contact 24-hour health support lines that may have been provided
    • if respiratory emergency in person with ALS
      • first call neurologist and respiratory physician in charge to determine required intervention
      • if needed, contact 24-hour health support lines that may have been provided
    • continue to be informed by reading/listening to reliable news sources
    • Reference - EAN recommendations on ALS and COVID-19 (EAN 2020 April 15)
  • information from ALS advocacy organizations

Stroke

Overview of Stroke-related Considerations During COVID-19 Pandemic

International Panel Recommendations on Management of Acute Ischemic Stroke

  • recommendations from an international panel, as reported in Int J Stroke 2020 May 3
  • COVID-19 infection associated with increased risk of developing acute stroke, especially if multiple organ dysfunction
    • underlying cause of stroke is unclear; there is preliminary evidence of association with hypercoagulopathy
    • other respiratory tract infections also associated with increased risk of stroke
    • stroke may develop after diagnosis of COVID-19 infection (consistent with sequence of events observed with acute stroke associated with other respiratory tract infections)
  • patients with acute stroke may have undiagnosed COVID-19 infection
    • appropriate screening not possible due to stroke-related neurological deficits and lack of relatives or others
    • COVID-19 infection may be in prodromal period
    • patient may be asymptomatic carrier of SARS-CoV-2 virus
    • COVID-19 infection may manifest with neurological deficits prompting stroke evaluation
  • for patient with stroke and suspected COVID-19 infection, consider pulmonary imaging using chest computerized tomography (CT) scan and/or chest x-ray to assess for radiological abnormalities
  • for assessing overall prognosis of patient with stroke and COVID-19 infection (to help with treatment decisions)
    • consider assessing organ dysfunction with Sequential Organ Failure Assessment (SOFA) score in addition to stroke-related factors
    • patients with COVID-19 infection and multiple organ dysfunction have high mortality; thus, their prognosis may not be influenced by acute stroke treatment
  • when conducting neuroimaging
    • consider chest CT concurrent with initial imaging in patients with acute stroke to assess for chest radiological abnormalities suggestive of COVID-19 infection
      • extent of pulmonary involvement may influence treatment decisions
      • note that chest CT may be normal in early phase of COVID-19 infection
    • if CT angiography or perfusion is being considered, consider first assessing for risk of contrast-induced nephropathy in patients with COVID-19 infection
      • COVID-19 infection associated with increased risk of renal insufficiency and subsequent acute kidney injury
      • renal impairments increase mortality in patients with COVID-19 infection and/or stroke
      • note that CT angiography or perfusion may not be needed if patient is not eligible for mechanical thrombectomy, such as if poor condition or if it is against patient or family wishes
    • consider using negative pressure carrier isolators to isolate patient with COVID-19 infection during neurovascular imaging
  • risks and benefits of IV thrombolysis depend on coagulation and inflammation that COVID-19 infection may influence
    • COVID-19 infection increases risk of coagulopathy, which is a contraindication for IV thrombolysis eligibility if severe enough
      • specific markers include reduced platelet count and elevated prothrombin time (PT), INR, and activated partial thromboplastin time (aPTT)
      • coagulopathy may be due to hepatic dysfunction; hepatic dysfunction without coagulopathy has unclear risks for patients having IV thrombolysis
      • if COVID-19 infection and other organ involvement, consider detailed coagulation profile
    • increased inflammation and hypercoagulability markers (leukocytosis, C reactive protein, and D dimers) are not a contraindication for IV thrombolysis but may increase postthrombolysis mortality and morbidity
  • endovascular therapy procedures may need to be modified to account for potential COVID-19 infection
    • anticipate need to modify protocols for transfers from emergency department to angiography suite and between facilities due in part to expected protocol changes to ensure early COVID-19 infection and reduced transmission risks
    • a stringent policy will be needed to determine eligibility for mechanical thrombectomy; current criteria include expected favorable outcomes and ability to rapidly initiate and perform procedure
    • consider using precautions that assume that the patient has COVID-19 infection in order to reduce delays in initiating and performing mechanical thrombectomy
    • advanced consenting methods such as waiver or remote consent may be needed depending on visitor policies
    • ventilation and sedation considerations for patients with confirmed or suspected COVID-19 infection
      • use low threshold for initiating intubation, mechanical ventilation, and general anesthesia to reduce exposure risk during procedure by maintaining ventilation through closed-circuit, avoiding unplanned intubations
      • consider obtaining tracheobronchial specimen at time of intubation for confirmation of suspected COVID-19 infection
      • perform intubation and mechanical ventilation in the most optimal settings possible, which may be before arrival to angiography suite, in order to reduce risk of transmission (endotracheal intubation is aerosol-generating)
    • considerations for angiography suite
      • all healthcare providers in angiography suite should wear surgical/medical masks, gloves, gown, and eye protection
      • use of particulate filtering facepiece respirator may depend upon availability and institutional policy
      • anticipate how procedures will be affected by limitations posed by additional personnel protective equipment
      • policies must exist that
        • identifies principles of decontamination and disinfectants for various categories of items and surfaces when patient with confirmed or suspected COVID-19 infection has a procedure
        • describes terminal cleaning protocol to ensure there is no transfer of SARS-CoV-2 to the next patient
        • reduce the longer than anticipated procedure times due to new precautionary measures
      • it is preferable to use negative pressure angiography suites if possible
  • considerations for antiplatelet agent use
    • consider avoiding antiplatelet agents following thrombolysis or endovascular therapy in patients with confirmed or suspected COVID-19 infection until the associated risks can be better defined
    • consider single or dual antiplatelet agents in patients with acute ischemic stroke who did not have thrombolysis or endovascular therapy and who have confirmed or suspected COVID-19 infection; it may be valuable to identify coagulation profile
  • for reducing risk of transmission while evaluating and managing patient with suspected stroke
    • healthcare providers caring for patient with acute stroke and COVID-19 infection are at increased risk of acquiring COVID-19 infection (precise risk not established, but likely lower than providers involved in evaluation of respiratory or infectious diseases and those performing aerosol-generating procedures)
    • assume COVID-19 infection in patient with stroke and clinical suspicion of COVID-19 infection; confirmation or exclusion of COVID-19 infection unlikely to occur during initial evaluations and decision-making for acute stroke
    • follow basic principles to reduce transmission risk
      • maintain ≥ 2 meter (6.6 feet) distance from patient unless it is absolutely necessary to be closer
      • use surgical mask, gloves, and gowns
      • wash hands
      • necessity of particulate filtering facepiece respirator is unclear
        • stroke evaluation does not require aerosol-generating procedures
        • decision also depends on availability, institutional policy, and regional prevalence of COVID-19 infection
    • stroke team evaluating patient should comprise minimum number of healthcare providers necessary
    • healthcare providers at high-risk of contracting COVID-19 infection should not be involved in evaluating patient if possible
    • maximize use of Telestroke where possible
      • not being in same room as patient is more effective strategy to reduce risk of transmission
      • consider having institutional ethics committee consider use of commercially available smartphone application systems when Telestroke not available
  • for reducing risk of environmental transmission
    • create a stroke green pathway separated from potentially contaminated emergency department to avoid direct interaction between stroke team and nonstroke patients with COVID-19 infection
      • pathway can include consultation rooms, head imaging rooms, and angiography suite
      • entrance into pathway can be based on prehospital screening
    • use ad-hoc pathway if suspected stroke patient had confirmed or suspected COVID-19 infection
      • sanitize environment
      • admit patient in an isolation ward after treatment, separating suspected from confirmed cases and using precautions against transmission
  • additional considerations for institutions
    • stroke centers must anticipate new challenges due to mismatch between demand and resources, including transfer of resources to COVID-19 needs
    • elective neuro-endovascular procedures may need to be deferred to accommodate demands placed on stroke centers
    • prospective registries may help characterize risk, manifestations, response to treatment strategies, and outcomes in stroke patients with COVID-19 infection
  • Reference - Int J Stroke 2020 May 3;:1747493020923234

Canadian Stroke Best Practices Guidance on Stroke During the COVID-19 Pandemic

  • hyperacute stroke care
    • stroke is a medical emergency regardless of the pandemic; public should be made aware that stroke is a medical emergency and persons with suspected stroke should be encouraged to seek medical attention without delay despite COVID concerns
    • continue to follow existing evidence-based stroke guidelines
    • hyperacute stroke response teams should remain available to treat acute stroke
    • modify workflow processes as appropriate within a Protected Code Stroke model
    • intubation may not always be necessary for all patients with confirmed or suspected COVID-19 who are having endovascular therapy
  • Telestroke considerations
    • Telestroke systems for hyperacute stroke care and support in decision making for thrombolysis and endovascular therapy are well-established; expand implementation to service all regions
    • toolkits based on current evidence and expert opinion are available within the Canadian Stroke Best Practice (CSBP) to aid with switching to virtual care - see CSBP Telestroke Toolkit 2017 PDF and CSBP Telestroke recommendations 2017 for details
    • take into account barriers to access and utilization and implement work-around solutions
  • acute stroke care considerations
    • continue to care for stroke patients in specialized acute stroke units where possible
    • education and basic skills training may be required for nonstroke experts caring for stroke patients
    • if critical care beds are limited, consider using ward beds with appropriate supports
  • secondary prevention
    • continue to implement secondary prevention services and follow-up, with revised workflows if needed, to reduce recurrent stroke incidence
    • model telemedicine enabled evaluation on topics defined in the Post Stroke Checklist (CSBP 2014 PDF) and core elements of stroke prevention care (CSBP 2017 PDF)
    • urgently conduct all investigations, including computed tomography (CT) and CT angiography scans, and electrocardiogram, for all patients with suspected stroke presenting within 24 hours of onset
  • stroke rehabilitation
    • persons with stoke must continue to have access to specialized inpatient, outpatient, early supported discharge, and community stroke rehabilitation
    • adapt essential components of stroke rehabilitation to follow public health recommendations on physical distancing and ensure personal protection for staff and patient when direct contact is required
    • telerehabilitation is an effective and well-accepted method of providing outpatient and community rehabilitation services; it is particularly important during the COVID-19 pandemic
  • Reference - Canadian Stroke Best Practices (CSBP) Guidance on Stroke During the COVID-19 Pandemic (CSBPPDF)

Korean Stroke Society Scientific Statement for Reducing SARS-CoV-2 Transmission During Acute Stroke Management

  • for outside angiography suite
    • use personal protective equipment - full-sleeved gown, N95 respirator, eye protection (goggles or face shields), and gloves
    • have non-intubated patients wear surgical mask
    • minimize close contact with patients; a brief neurological examination suffices for National Institute of Health Stroke Scale
    • limit neuroimaging to detecting large vessel occlusions and proceed to recanalization treatment decisions; avoid advanced neuroimging until COVID-19 infection has been excluded
    • after IV thrombolysis or endovascular therapy, place patient in negatively pressurized or properly isolated room for monitoring
    • reduce in-hospital patient transportation as much as possible
    • if transportation is necessary
      • use isolation stretcher or wheelchair with negative pressure
      • clear out the hallway during in-hospital patient transportation
  • for angiography suite
    • use negatively pressurized angiography suite if available
    • if negatively pressurized angiography suite not available
      • designate an angiography suite for treating a stroke patient with COVID-19 infection
      • prepare isolation measures before using suite
      • after treatment, perform complete disinfection and decontamination
    • designate healthcare workers for treating possible COVID-19 infection cases and ensure they don and doff their personal protective equipment properly
    • turn off automatic doors to angiography suite
    • during angiography procedure, shut down doors, restrict access, and minimize number of medical staff (1 medical doctor may assume role of crisis resource management)
    • have patient wear surgical mask unless intubated or using oxygen mask
    • properly discard disposable items
    • after procedure, admit patient to negatively pressurized or properly isolated intensive care unit or stroke unit
  • PubMed32392907Journal of strokeJ Stroke20200512Reference - J Stroke 2020 May 12 early online

Society for Neuroscience in Anesthesiology & Critical Care (SNACC) Consensus Statement on Anesthetic Management of Endovascular Treatment of Acute Ischemic Stroke During COVID-19 Pandemic

  • this SNACC statement is endorsed by Society of Vascular & Interventional Neurology (SVIN), Society of NeuroInterventional Surgery (SNIS), Neurocritical Care Society (NCS), and European Society of Minimally Invasive Neurological Therapy (ESMINT)
  • adapt these recommendations to local institutional workflows while continuously monitoring stroke quality measures and patient outcomes
  • use airborne precautions for all endovascular therapy (EVT) procedures including N95 mask or powered air purifier respirator, surgical cap, eye protection, full gown, and double gloves
  • minimize delays in cerebral reperfusion in eligible patients
  • base choice between generalized anesthesia (GA) and monitored anesthesia care (MAC) on individual patient
    • GA not recommended for all patients, but lower threshold for using GA should be considered to avoid need for emergency conversion from MAC to GA
    • use of MAC best is suited for experienced centers with low rate of conversion from MAC to GA
    • anesthesiologist and interventionalist should discuss optimal anesthetic technique before patient enters interventional radiology suite
  • assess patient for characteristics in favor of generalized anesthesia, including
    • acute respiratory distress, hypoxemia, or requirements for high-flow oxygen
    • active cough
    • inability to protect airway
    • active vomiting
    • occlusions in posterior circulation or dominant cerebral hemisphere
    • moderate-to-severe clinical condition - National Institutes of Health Stroke Scale (NIHSS) > 15 points or Glasgow Coma Scale (GCS) < 9 points
    • agitated or uncooperative behavior
    • aphasic
  • if patient has any of the above characteristics, consider generalized anesthesia
    • induce GA in emergency department if it can be done safely in a negative-pressure location; otherwise induce in interventional radiology suite
    • only essential personnel should be involved
    • avoid high-flow pre-oxygenation
    • most experienced person available should intubate using rapid sequence induction with video-laryngoscopy
    • ensure that vasopressors are immediately available if needed
    • maintain systolic blood pressure > 140 mm Hg, and SPO2 > 94%, and normocarbia
    • use HEPA filter on endotracheal tube and CO2 sampling line
    • avoid circuit disconnections
    • extubate in negative-pressure location if possible, and reduce risk of coughing as much as possible
  • if monitored anesthesia care is performed
    • have patient wear surgical mask
    • avoid high-flow nasal cannula oxygen
    • carefully titrate sedation to avoid oro- or nasopharyngeal airway insertion or chin lift/jaw thrust
    • consider using expiratory viral filter on oxygen masks
  • Reference - J Neurosurg Anesthesiol 2020 Apr 8 early online

Society of Vascular and Interventional Neurology (SVIN) Guidance Statement on Mechanical Thrombectomy During COVID-19 Pandemic

  • prehospital care
    • triage every patient for symptoms and signs of COVID-19, including potential contact
    • if suspected COVID-19 infection, have patient wear a surgical mask and place them in isolation in a negative-pressure room
      • use telecommunication (phone or video) if available
      • identify minimum number of providers needed to care for patient
      • wear personal protective equipment for any patient contact
    • if pulmonary symptoms, consider noncontrast chest computed tomography (CT) at same time as head and neck CT/CT angiography, provided this addition does not incur a > 5-minute delay
      • if patient has already had a head CT, do not perform chest CT before starting reperfusion therapies
    • consider direct to angiography suite approach for stable patients with stroke symptoms onset ≤ 24 hours previous, who are transferred from other hospitals, with last neuroimaging ≤ 2 hours previous, and with imaging signs indicating likely benefit from endovascular therapy (ASPECT score ≥ 7 points)
  • consent and healthcare proxy considerations
    • if patient not consentable, obtain consent from legally authorized representative or, if not available, 2 physician emergency consents
    • if patient is consentable, perform verbal procedural consent with witness, including consent for general anesthesia, and perform verbal healthcare proxy consent with a witness
  • airway preparation
    • alert anesthesiologist early if patient has confirmed or suspected COVID-19 infection
    • consider conscious sedation as first-line sedation if patient stable; discuss having a dedicated COVID-19 glidescope ready in the angiography suite in case of deterioration
    • consider early and controlled intubation if patient at risk of airway deterioration (such as orthopnea, tachypnea, respiratory distress, or high oxygen requirement), airway cannot be protected, active vomiting, agitation, or uncooperative behavior
    • discuss in advance if intubation would take place in negative-pressure room, angiography suite, or elsewhere
    • discuss in advance whether anesthesia presence is required in the room or as needed for intubation or hemodynamic issues
  • preparing thrombectomy room before patient arrival
    • remove all unnecessary items to reduce postprocedure cleaning, such as lead aprons that will not be used
    • cover cabinets and countertop items with plastic, or remove items
    • prepare all procedural elements (such as medications, devices, and bags) in the room before patient arrival to reduce time patient is in the room, protect room equipment, and prevent breaking scrub
    • have observer watch provider don their gown and protective gear
    • use double gloves, face mask, N95 mask in COVID-19 suspected or positive patients, shoe covers, and protective gear
    • also use hanging lead shields and standing lead shields as another layer of protection
    • have hand sanitizer near the doors entering or exiting angiography or recovery rooms
    • designate an area to place the phone and pager of the proceduralist in the control room
  • during thrombectomy
    • minimize number of staff procedure room (consider 1 nurse, 1 technologist, and 1 physician) to reduce exposure to COVID-19 and conserve protective gear
    • tape the doors to the procedure room or post a sign so other people do not enter inadvertently without protective gear
    • discuss with primary team additional blood tests proceduralist can draw off the sheath for COVID-19 and stroke workup, such as, arterial blood gas, complete blood count, chem 7, liver function tests, and cholesterol panel
    • have an observer watch providers remove their gown and gear
    • ensure that any trash is completely inside trash bag
  • postthrombectomy assessments
    • if current or expected shortage of critical care beds, move nonintubated stable patients to a step-down unit with appropriate nursing expertise
    • reduce postthrombectomy neurological exams and access site checks if possible, and have 1 provider perform them, to conserve personal protective equipment
    • when transferring patient to receiving team, have gowned provider check the patient's neurological exam, vital signs, and/or access site before removing their personal protective equipment; this can count as the 15- or 30-minute postthrombectomy check depending on the elapsed time
    • use telecommunication/video to continuously monitor patient if possible
    • otherwise, consider additional neurological exam, vital sign, and/or access site check 15 or 30 minutes after transfer, and then after 1 hour and again after 1 hour; thereafter, these combined checks can occur every 4 hours
    • adjust frequency combined neurological, vital sign, and/or access site checks depending on patient intubation/sedation status, hemodynamic stability, and concern for access site bleeding
  • postthrombectomy therapy and care
    • perform extubation (if necessary) in negative-pressure room
    • postpone or delay all but absolutely necessary tests until COVID-19 has been ruled out (to protect staff, conserve protective gear, and prevent virus trafficking)
    • communicate with family by telephone as visitation rights may be restricted
    • during rounds, see patients on contact or droplet precautions at the end (assuming they are medically stable) to avoid viral spread to patients not on precaution
    • if any provider develops symptoms of cough, fever, or shortness of breath, they should seek testing and potential quarantine based on local protocols
    • evaluate patient mental health where appropriate
    • consider testing patient for COVID-19 (if not already done) if patient is being transitioned to postacute care facility
  • debrief to learn from each other and perform quality improvement
  • Reference - Stroke 2020 Apr 29 early online

Proposed Algorithm for Endovascular Therapy for Acute Ischemic Stroke During the COVID-19 pandemic

  • this algorithm, proposed by a group at the University of Cincinnati, is reported in Stroke 2020 Apr 30 early online
  • suspect COVID-19 infection in patients with any of
    • temperature > 38 degrees C (100.4 degrees F)
    • respiratory rate > 24 breaths/minute
    • any of the following symptoms ≤ 7 days previous: fever, chills, myalgias, rhinorrhea, sore throat, cough, shortness of breath, nausea, vomiting, headache, abdominal pain, or diarrhea
    • exposure to any person with confirmed or suspected COVID-19 infection ≤ 14 days previous
  • airway management for patients with suspected or confirmed COVID-19 infection
    • if patient is not expected to need intubation
      • do not intubate
      • use masks on patient and staff for droplet/contact precautions
      • use N95 masks on staff during aerosolizing procedures
      • attach viral filters to suctioning equipment
    • if patient requires intubation
      • intubate in a negative airflow room before arrival to interventional radiology suite
      • prioritize staff safety and first-pass success
      • preserve cerebral perfusion pressure
      • use viral exhaust filters
      • avoid ventilator circuit disconnections
      • extubate patient in intensive care unit as soon as it is safe to do so in order to preserve resources
  • for patients hospitalized for COVID-19 infection
    • conduct baseline neurological exam in addition to routine vital sign checks in current floor level of care
    • for patients on routine mechanical ventilation who are hemodynamically stable, wean sedation every 8 hours to assess for signs of large vessel occlusion (gaze deviation and focal weakness following application of bilateral nail bed pressure)
    • if stroke strongly suspected, have stroke specialist evaluate for stroke and conduct imaging concurrently; if stroke not strongly suspected, conduct specialist evaluation before imaging in order to avoid unnecessary risk to staff during transportation
    • when assessing patient for endovascular therapy, base premorbid level of function on patient function before COVID-19 infection
    • consider not offering EVT to patients who are not likely to benefit, such as patients not stable enough for transport outside intensive care unit, undergoing prone positioning, requiring neuromuscular blockade, have ventilation due to acute respiratory distress syndrome, or are on extracorporeal membrane oxygenation
  • PubMed32352910StrokeStroke20200430STROKEAHA120029863STROKEAHA120029863Reference - Stroke 2020 Apr 30 early online

Evidence in Patients with Stroke

  • Study Summary
    no dramatic neurological improvement within 24 hours of thrombectomy in adults with acute ischemic stroke with large vessel occlusion and COVID-19 infection, and death during hospitalization reported in 60%, but evidence limited
    Details
    studySummary
    • Cohort Studybased on small retrospective cohort study
    • 10 adults (median age 59 years, 80% men) with acute ischemic stroke with large vessel occlusion
    • median NIHSS score 22 points (total score range 0-42 points; score > 22 points indicates severe symptoms)
    • COVID-19-related symptoms and signs included dyspnea with oxygen saturation < 94% on room air in 30% of patient;, fever in 50%; cough, shortness of breath, or respiratory stress in 70%; and opactities on chest CT in 100% of 8 patients who had chest CT
    • no COVID-19-related symptoms in 20%
    • acute stroke treatment included
      • IV thrombolysis in 50% of patients (at median 175 minutes after stroke onset)
      • mechanical thrombectomy in 100% of patients (all within 6 hours of stroke onset), with successful recanalization in 90%
    • no patients had "dramatic" neurological improvement within 24 hours of thrombectomy; median NIHSS 25 points
    • death during hospitalization in 60% of patients
    • intracranial proximal artery reocclusion within 24 hours in 40% of patients
    • symptomatic intracranial hemorrhage within 24 hours in 0% of patients
    • PubMed32466736StrokeStroke20200529STROKEAHA120030574STROKEAHA120030574Reference - Stroke 2020 May 29 early online

Additional Resources

Pediatric Patients

  • about 2% of confirmed COVID-19 cases reported in cohort studies from China and United States were in children and adolescents
  • most commonly reported symptoms in children are similar to those of other viral respiratory infections
    • fever
    • cough
    • nasal congestion
    • rhinorrhea
    • sore throat
  • other reported symptoms include diarrhea, vomiting, fatigue, headache, poor appetite, and shortness of breath
  • mild respiratory disease reported in about half of children with confirmed or suspected COVID-19, and another reported 30% have moderate respiratory disease
  • multisystem inflammatory syndrome in children (MIS-C) is a new syndrome being reported in a small number of children during the COVID-19 pandemic
    • syndrome has features similar to other pediatric inflammatory conditions including Kawasaki disease
    • children often require intensive care
  • testing and screening for COVID-19
    • Centers for Disease Control and Prevention (CDC) provides specific guidance for testing neonates born to mothers with suspected or confirmed COVID-19
    • testing in infants > 12 months and children is similar to that in the general population
  • management of pediatric patients with COVID-19
    • decision to admit pediatric patient with mild-to-moderate COVID-19 should be made on case-by-case basis
    • currently there are no approved antiviral drugs for COVID-19; FDA has issued Emergency Use Authorization for use of remdesivir for treatment of suspected or confirmed COVID-19 in children and adults hospitalized with severe disease
    • supportive care may help to relieve symptoms and should include support of vital organ functions in severe cases
    • professional organizations provide initial guidance for management of neonates born to mothers with COVID-19
  • 42 deaths among children with confirmed COVID-19 reported by state health departments in United States as of May 27, 2020
  • infection control
    • pediatric population likely contributes to transmission of COVID-19 in the community due to the higher prevalence of mild and asymptomatic disease; children, with help from parents, can adopt measures to slow spread of COVID-19 including frequent handwashing and social distancing
    • because of concerns about viral transmission from asymptomatic children, Royal College of Paediatrics and Child Health/British Paediatric Allergy Immunity and Infection Group (RCPCH/BPAIIG) recommends only performing oropharynx exam in children if essential and, if considered essential, using personal protective equipment even if child does not have symptoms consistent with COVID-19
  • health maintenance for all children during pandemic
    • American Academy of Pediatrics (AAP) strongly supports continued provision of health care for children during the COVID-19 pandemic
      • pediatricians should work with families to ensure that all children (of any age) are current on immunizations and regular well-visits
        • identify children who have missed well-child visits or recommended immunizations
        • contact families of these children to schedule in person appointments
        • get children back on schedule as quickly as possible
      • telehealth may be used for acute or chronic care and also for well visits, provided components of the exam are completed in person in the clinic when circumstances allow
    • existing mental health problems in children may worsen during pandemic, and children who rely on receiving mental health services in the school setting may be particularly vulnerable due to school closures
  • see COVID-19 and Pediatric Patients for details

Pregnancy

  • COVID-19 infection (coronavirus disease 2019) is an acute respiratory disease caused by novel coronavirus SARS-CoV-2
  • many physiologic and anatomic changes of pregnancy affect the respiratory system and increase susceptibility to infections in general, which may complicate or delay the diagnosis of COVID-19 and/or the clinical course of the disease in infected women
  • respiratory illnesses during pregnancy may be associated with increased infectious morbidity and high maternal mortality rates but it is currently unknown if pregnant women have more severe disease as a result of COVID-19 infection
  • initial evaluation and management of pregnant women with suspected or confirmed COVID-19 depends on presence of symptoms, severity of symptoms, and clinical and social risks for COVID-19 infection
  • screening for COVID-19 in pregnant patients is similar to that in the general population
  • follow general recommendations for infection prevention in the management of pregnant women with suspected or confirmed COVID-19
  • outpatient, inpatient, or intensive care for management of COVID-19 infection in pregnant women
    • there is no specific antiviral treatment for COVID-19, but supportive care may help to relieve symptoms and should include support of vital organ functions in severe cases
    • determination of outpatient, inpatient, or intensive care management of COVID-19 infection in pregnant women is based on severity of symptoms, presence of high-risk obstetric complications, and clinical and/or social risk factors for COVID-19 infection
    • protocols for outpatient and inpatient monitoring of COVID-19 infection in pregnant women
      • outpatient monitoring includes
        • self-monitoring of symptoms and follow-up with healthcare provider if symptoms worsen
        • follow-up with healthcare provider at least once within 2 weeks of COVID-19 diagnosis
      • inpatient monitoring and management includes
        • frequent vital sign assessment
        • considerations for intubation, alternatives to intubation for safe oxygen delivery, and patient positioning
  • antenatal, intrapartum, and postpartum considerations during COVID-19 pandemic
    • consider mental health needs of pregnant women during COVID-19 pandemic
    • considerations for routine prenatal care during COVID-19 pandemic
      • unless directed otherwise by local clinic policies, women should be advised to attend routine antenatal care unless they meet criteria for self-isolation, in which case, appointments should be deferred for 14 days
      • screen for COVID-19 symptoms and possible exposure prior to having patient report for in-person appointments
      • patients with certain high-risk obstetric conditions and/or comorbidities should be provided appropriate and necessary prenatal care and antenatal surveillance when indicated
      • consider alternate prenatal care approaches to help control the spread of COVID-19, including
        • patient assessments via phone or telehealth
        • alternate prenatal care schedules
    • women with suspected or confirmed COVID-19 infection should notify the obstetric unit prior to arrival to allow for appropriate infection control procedures
    • antenatal considerations
      • antenatal fetal surveillance
        • during acute illness, fetal management should be similar to that provided to any critically ill pregnant person
        • ultrasound
          • elective ultrasound exams should not be performed
          • if risk of exposure and infection within the community is greater than benefit of testing, consider postponing or canceling some testing or exams
          • detailed mid-trimester anatomy ultrasound examination may be considered following first trimester maternal COVID-19 infection
          • ultrasound assessment of fetal growth is indicated in pregnant women with COVID-19 infection due to risk of fetal growth restriction
      • all pregnant women with suspected or confirmed COVID-19 infection should receive prophylactic low molecular weight heparin upon admission to reduce risk of venous thromboembolism unless birth is expected within 12 hours
      • antenatal corticosteroids for fetal maturation
        • for pregnancies with suspected or confirmed COVID-19 between 24 0/7 weeks and 33 6/7 weeks gestation at risk of preterm birth within 7 days, antenatal corticosteroids should continue to be offered as recommended
        • for pregnancies between 34 0/7 and 36 6/7 weeks gestation at risk of preterm birth within 7 days, antenatal corticosteroids should not be offered
        • modifications to care should be individualized, weighing neonatal benefits of antenatal corticosteroids with risk of potential harm from possible immunosuppression in infected patients
      • benefits of magnesium sulfate for fetal neuroprotection should be weighed against potential risks of maternal respiratory depression in patients with symptomatic infection while also taking gestational age into account
    • labor and delivery
      • general considerations
        • delayed cord clamping is still appropriate in the setting of suspected or confirmed COVID-19 infection with use of appropriate personal protective equipment
        • scheduled inductions of labor and cesarean deliveries should continue to be performed as indicated with considerations made to availability of healthcare personnel and access to readily available resources
        • number of visitors should be limited during in-hospital maternity care to minimize risk of infection
      • setting and mode of delivery
        • timing of delivery should not be affected by COVID-19 infection in most cases
        • cesarean delivery should be based on obstetric (fetal or maternal) indications and not based on suspected or confirmed COVID-19 infection
        • no intrauterine infection by vertical transmission reported in women with COVID-19 in late pregnancy
      • maternal and fetal monitoring should be continued per standard practice with some additional considerations for women with suspected or confirmed COVID-19 depending on severity of symptoms
    • postpartum management
      • tubal sterilization (other than that performed during cesarean delivery) is an elective procedure, therefore postpartum tubal ligations should be deferred in patients who are COVID-19 positive and alternative forms of contraception can be offered
      • infants born to mothers with confirmed COVID-19 should be considered persons under investigation and should be isolated per United States Centers for Disease Control and Prevention (CDC) guidance
      • mother-infant contact
        • decision whether to separate a mother with suspected or confirmed COVID-19 and her infant should be made on a case-by-case basis using shared-decision making between the mother and the clinical team
        • if rooming-in of mother and newborn occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, consider implementing measures to reduce exposure of the newborn to COVID-19
      • expedited discharge from the hospital may be considered when both mother and infant are healthy to limit risk of exposure and infection to COVID-19
      • all women with confirmed COVID-19 should be given prophylactic low molecular weight heparin for ≥ 10 days upon hospital discharge regardless of mode of birth
      • consider modifying or reducing postpartum follow-up appointments to decrease risk of COVID-19 spread and exposure
      • breastfeeding for women with suspected or confirmed COVID-19
        • for mother/infant pairs who are rooming-in, breastfeeding can be considered with use of proper hand washing and other preventative measures to decrease risk of exposure for infant
        • for mother/infant pairs who are temporarily separated, mothers who wish to breastfeed should be encouraged to express their breastmilk to establish and maintain milk supply and expressed milk should be fed to newborn by a healthy caregiver
  • see COVID-19 and Pregnant Patients topic for details

References

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