Considerations on biologicals for patients with allergic disease in times of the COVID-19 pandemic: An EAACI statement

Poor outcome of SARS-CoV-2 infection in patients with severe asthma on biologic therapy

BACKGROUND

It is unclear whether asthma and asthma medications increase or decrease the risk of severe COVID-19, and this is particularly true for patients with severe asthma receiving biologics.

OBJECTIVES

The aim of this study was to assess incidence and disease course of COVID-19 in patients with severe asthma on biologic therapy (omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab), as compared with COVID-19 data from the general Dutch population.

METHODS

COVID-19 cases were identified through a prospective ongoing survey between March 17 and April 30, 2020 among all severe asthma specialists from 15 hospitals of the Dutch Severe Asthma Registry RAPSODI. From these cases, data was collected on patient characteristics, including co-morbidities, COVID-19 disease progression and asthma exacerbations. Findings were then compared with COVID-19 data from the general Dutch population.

RESULTS

Of 634 severe asthma patients who received biologic therapy in RAPSODI, 9 (1.4%) were diagnosed with COVID-19. Seven patients (1.1%) required hospitalization for oxygen therapy, of which 5 were admitted to the intensive care for intubation and mechanical ventilation. One patient died (0.16%). All intubated patients had ≥1 co-morbidities. Odds (95%CI) for COVID-19 related hospitalization and intubations were 14 (6.6-29.5) and 41 (16.9-98.5) times higher, respectively, compared to the Dutch population. One patient presented with an asthma exacerbation.

CONCLUSION

Patients with severe asthma using biologic therapy showed to have a more severe course of COVID-19 compared to the general population. This may be due to co-morbidities, the severity of asthmatic airway inflammation, the use of biologics, or a combination of these.

COVID-19 and Pediatric Asthma: Clinical and Management Challenges

Asthma is the most frequent chronic condition in childhood and a current concern exists about asthma in the pediatric population and its risk for severe SARS-CoV-2 infection. Although all ages can be affected, SARS-CoV-2 infection has lower clinical impact on children and adolescents than on adults. Fever, cough and shortness of breath are the most common symptoms and signs in children; wheezing has not been frequently reported. Published studies suggest that children with asthma do not appear to be disproportionately more affected by COVID-19. This hypothesis raises two issues: is asthma (and/or atopy) an independent protective factor for COVID-19? If yes, why? Explanations for this could include the lower IFN-α production, protective role of eosinophils in the airway, and antiviral and immunomodulatory proprieties of inhaled steroids. Additionally, recent evidence supports that allergic sensitization is inversely related to ACE2 expression. Obesity is a known risk factor for COVID-19 in adults. However, in the childhood asthma–obesity phenotype, the classic atopic Th2 pattern seems to predominate, which could hypothetically be a protective factor for severe SARS-CoV-2 infection in children with both conditions. Finally, the return to school activities raises concerns, as asymptomatic children could act as vectors for the spread of the disease. Although this is still a controversial topic, the identification and management of asymptomatic children is an important approach during the SARS-CoV-2 epidemic. Focus on asthma control, risk stratification, and medication adherence will be essential to allow children with asthma to return safely to school.

Considerations for asthma management and viral transmission in the era of COVID-19

Background: As the global COVID-19 pandemic has unfolded, there has been much debate surrounding the optimal management of patients with asthma who are at risk of or contract COVID-19, whether asthma and steroids are risk factors for severe COVID-19, and how transmissible the virus is among children. Objective: The objective of this study is to provide allergists and other clinicians with pearls pertaining to the management of patients with asthma in the setting of the COVID-19 pandemic and to provide some information regarding the risk of transmission among the pediatric population. Methods: Utilizing the case of one of our own patients with asthma who developed COVID-19 as context, we review the recent literature discussing the risk of COVID-19 in patients with asthma, the management of asthma medications in the time of the pandemic, and the risk of viral transmission. Results: Despite initial reports that asthma was a risk factor for developing severe COVID-19, subsequent investigation has shown that this is likely not true. Additionally, the use of systemic or inhaled glucocorticoids does not appear to increase the risk of severe COVID-19, but there is no evidence guiding the use of biologic therapy. There is conflicting evidence regarding the ability of children to transmit the virus. Conclusion: We provide pearls that asthma does not appear to be associated with an increased risk of COVID-19 and continued use of inhaled corticosteroids appears to be safe. While there is no evidence guiding the use of biologic therapies, a recent position paper suggests that they should be continued unless a patient contracts COVID-19, at which point they should be held until clinical recovery occurs.

The impact of COVID-19 pandemic on the management of patients with chronic urticaria: An observational two-center study from Turkey

The Coronavirus Disease 2019 (COVID‐19) outbreak significantly affected the clinical practice in hospitals and the management of many diseases. The aim of this study was to evaluate the effect of pandemic‐related factors on the severity and course of chronic urticaria (CU). A total of 194 CU patients who were on regular follow‐up, were enrolled in the study. The disease activity was assessed by means of the weekly urticaria activity score (UAS7) and urticaria control test (UCT). Patients were divided into two subgroups according to their disease aggravation as “aggravated” and “non‐aggravated”. Two groups were compared in terms of demographic, clinical, COVID‐19‐associated parameters, and parameters related with the effect of COVID‐19 pandemic on CU management. The omalizumab use was statistically higher (P = .017), and the systemic corticosteroid use was statistically lower (P = .025) in the “aggravated” group. Adherence to quarantine was significantly lower in the “aggravated” group (P = .027). 173 patients (89.2%) were unable to contact a dermatologist during the pandemic. Among 186 patients who received treatment for CU before the pandemic, 48 (25.8%) did not continue the existing treatment during the pandemic. CU aggravated in one patient with COVID‐19 and remained stable in the other. This study showed that CU patients, especially those on omalizumab therapy, had difficulties in attending medical care and even in the maintenance of their existing therapies during the pandemic. Creating novel follow‐up and treatment models as well as the increased use of teledermatology might be beneficial in the management of this life‐disturbing condition.

Advances and recent developments in asthma in 2020

In this review, we discuss recent publications on asthma and review the studies that have reported on the different aspects of the prevalence, risk factors and prevention, mechanisms, diagnosis, and treatment of asthma. Many risk and protective factors and molecular mechanisms are involved in the development of asthma. Emerging concepts and challenges in implementing the exposome paradigm and its application in allergic diseases and asthma are reviewed, including genetic and epigenetic factors, microbial dysbiosis, and environmental exposure, particularly to indoor and outdoor substances. The most relevant experimental studies further advancing the understanding of molecular and immune mechanisms with potential new targets for the development of therapeutics are discussed. A reliable diagnosis of asthma, disease endotyping, and monitoring its severity are of great importance in the management of asthma. Correct evaluation and management of asthma comorbidity/multimorbidity, including interaction with asthma phenotypes and its value for the precision medicine approach and validation of predictive biomarkers, are further detailed. Novel approaches and strategies in asthma treatment linked to mechanisms and endotypes of asthma, particularly biologicals, are critically appraised. Finally, due to the recent pandemics and its impact on patient management, we discuss the challenges, relationships, and molecular mechanisms between asthma, allergies, SARS-CoV-2, and COVID-19.

COVID-19 and allergy: How to take care of allergic patients during a pandemic?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as COVID-19, is a new strain of coronavirus that has not been previously identified in humans. SARS-CoV-2 is recognized as a highly contagious respiratory virus with severe morbidity and mortality, especially in vulnerable populations. Being a novel disease, everyone is susceptible, there are no vaccine and no treatment. To contain the spread of the disease, health authorities throughout the world have restricted the social interactions of individuals in various degrees. Allergists, like other physicians, are faced with the challenge of providing care for their patients, while protecting themselves and patients from getting infected, with strategies that are in continuous evolution as states work through the different stages of social distance. Allergist provides care for patients with the most common non-communicable disease in the world: asthma, allergic rhinitis, food allergy, venom allergy, drug allergy atopic dermatitis, and urticarial syndromes. Some of these diseases are not only considered risk factors for severe reactions but also have symptoms such as cough and sneezing that are in differential diagnosis with COVID-19. As we move forward, allergy symptoms may prevent patients from working, go to school, or access medical services that increasingly are allowing only asymptomatic individuals. In this review, we will outline how to take care safety of different allergic patients during the pandemic.

Asthma and COVID-19: What do we know now

The COVID-19 pandemic has presented challenges in symptomology identification, diagnosis, management and follow-up in common respiratory diseases, and in particular asthma. Research is rapidly ongoing to try and understand how the SARS-CoV-2 virus affects individuals with asthma, as well as, how underlying asthma affects Covid-19 risk, symptomology and prognosis. In light of this unique medical challenge, clinicians are faced with case-by-case based decisions to implement or continue current asthma therapy. This review will discuss the current literature regarding asthma and COVID-19 based on best available evidence at this time (See box 1).

COVID-19 and biologics in severe asthma: data from the Belgian Severe Asthma Registry

Epidemiological studies suggest that patients with asthma are not at an increased risk of severe coronavirus disease 2019 (COVID-19) caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1–3]. Recent studies indicate that the severity of COVID-19 in patients with asthma is likely to depend on multiple factors. A type 2-low asthma phenotype, use of oral corticosteroids and severe asthma could be aggravating factors, while maintenance treatment with inhaled corticosteroids (ICS) and good asthma control are probably protective [4]. However, there is currently scarce information on the risk associated with COVID-19 in subjects with severe asthma and/or the use of biologics. Since eosinopenia is a biomarker for the severity of COVID-19 [5], the eosinophil depletion induced by anti-IL5 and anti-IL5 receptor blocking monoclonal antibodies raises concern in patients and their treating physicians.

In a cohort of severe asthma patients, a small number of COVID-19 cases was found; none resulted in death or a very severe disease course. Use of biologics for severe allergic or severe eosinophilic asthma was not associated with a higher risk of COVID-19. https://bit.ly/3ndZmyD

Change in Allergy Practice during the COVID-19 Pandemic

Background

International guidelines in asthma and allergy has been updated for COVID-19 pandemic and pandemic has caused dramatic changes in allergy and immunology services. However, it is not known whether specialty-specific recommendations for COVID-19 are followed by allergists.

Objectives

By conducting this study, we aimed to determine the attitudes and experiences of adult/pediatric allergists on allergy management during COVID-19.

Method

We used a 20-question survey to elicit data from allergists (residents and pediatric and adult allergists registered to the Turkish National Society of Allergy and Clinical Immunology) across Turkey via e-mail. We analyzed the data statistically for frequency distributions and descriptive analysis.

Results

A total of 183 allergists participated in the survey. Telemedicine was used for management of asthma (73%), allergic rhinitis (53%), atopic dermatitis (51%), chronic urticaria/angioedema (59%), drug hypersensitivity (45%), food allergy (48%), venom allergy (30%), anaphylaxis (22%), and hereditary angioedema (28%). Thirty-one percent of the respondents discontinued subcutaneous immunotherapy (SCIT) during the COVID-19 pandemic. Thirty-four percent of the physicians reported interruption of systemic steroid use in asthma patients, and 25% of the respondents discontinued biological therapy.

Conclusions

Allergists in Turkey have been using telemedicine at a high rate during the COVID-19 pandemic for asthma and rhinitis. The continuation rate of SCIT was low while the discontinuation rate of biologicals and systemic steroid use in asthma was high in Turkey. Our study results and learning from the experiences of other countries and specialties may help to optimize allergy practice and compatibility with international guidelines.

Management of the patient with allergic and immunological disorders in the pandemic COVID-19 era

The pandemic COVID-19 abruptly exploded, taking most health professionals around the world unprepared. Italy, the first European country to be hit violently, was forced to activate the lockdown in mid-February 2020. At the time of the spread, a high number of victims were quickly registered, especially in the regions of Northern Italy which have a high rate of highly-polluting production activities. The need to hospitalize the large number of patients with severe forms of COVID-19 led the National Health System to move a large number of specialists from their disciplines to the emergency hospital departments for the treatment of COVID-19. Furthermore, the lockdown itself has limited the possibility for general practitioners and pediatricians to be able to make outpatient visits and/or home care for patients with chronic diseases. Among them, the patient with atopic diseases, such as asthma, rhinitis and atopic dermatitis, is worthy of particular attention as she/he is immersed in a studded negative scenario with the onset of spring, a factor that should not be underestimated for those who suffer from pollen allergy. The Italian Society of Asthma Allergology and Clinical Immunology, to quickly deal with the lack of references and specialist medical procedures, has produced a series of indications for immunologic patient care that are reported in this paper, and can be used as guidelines by specialists of our discipline.

A compendium answering 150 questions on COVID-19 and SARS-CoV-2

In December 2019, China reported the first cases of the coronavirus disease 2019 (COVID‐19). This disease, caused by the severe acute respiratory syndrome–related coronavirus 2 (SARS‐CoV‐2), has developed into a pandemic. To date, it has resulted in ~9 million confirmed cases and caused almost 500 000 related deaths worldwide. Unequivocally, the COVID‐19 pandemic is the gravest health and socioeconomic crisis of our time. In this context, numerous questions have emerged in demand of basic scientific information and evidence‐based medical advice on SARS‐CoV‐2 and COVID‐19. Although the majority of the patients show a very mild, self‐limiting viral respiratory disease, many clinical manifestations in severe patients are unique to COVID‐19, such as severe lymphopenia and eosinopenia, extensive pneumonia, a “cytokine storm” leading to acute respiratory distress syndrome, endothelitis, thromboembolic complications, and multiorgan failure. The epidemiologic features of COVID‐19 are distinctive and have changed throughout the pandemic. Vaccine and drug development studies and clinical trials are rapidly growing at an unprecedented speed. However, basic and clinical research on COVID‐19–related topics should be based on more coordinated high‐quality studies. This paper answers pressing questions, formulated by young clinicians and scientists, on SARS‐CoV‐2, COVID‐19, and allergy, focusing on the following topics: virology, immunology, diagnosis, management of patients with allergic disease and asthma, treatment, clinical trials, drug discovery, vaccine development, and epidemiology. A total of 150 questions were answered by experts in the field providing a comprehensive and practical overview of COVID‐19 and allergic disease.

COVID-19 in the Pediatric Population-Review and Current Evidence

Purpose of Review

Coronavirus disease 2019 (COVID-19) pandemic has major health and economic impacts. We review disease characteristics in children.

Recent Findings

Children comprise 1–2% of the diagnosed cases, and typically suffer mild disease. The median age of infected children is 3.3–11 years, and male/female ratio is 1.15–1.55. Common symptoms in children include upper respiratory symptoms (26–54%), cough (44–54%), fever (32–65%), and gastrointestinal (15–30%) symptoms. Substantial proportion (4–23%) are asymptomatic. Death rates are up to 0.7%. Risk factors associated with severe disease are neonatal age group, male gender, lower respiratory tract disease, and pre-existing medical conditions. Vertical transmission was reported. Multisystem inflammatory syndrome (MIS), characterized by fever, multisystem organ involvement, and laboratory markers of inflammation, causes critical illness in > 50% of cases and is increasingly reported from endemic countries. Indirect effects of the coronavirus epidemic include higher rates of psychiatric morbidities, education loss, unhealthy lifestyle changes, and increased child neglect. Vaccines are in clinical trials and immunogenicity has not yet been shown in children.

Summary

Overall, COVID-19 has lower incidence and causes milder disease in children compared with adult patients. MIS is a rare severe complication more common in children. More data on the efficacy and safety of antivirals in children are needed.

Immunomodulatory Therapeutic Proteins in COVID-19: Current Clinical Development and Clinical Pharmacology Considerations

The coronavirus disease 2019 (COVID‐19) pandemic caused by infection with SARS‐CoV‐2 has led to more than 600 000 deaths worldwide. Patients with severe disease often experience acute respiratory distress characterized by upregulation of multiple cytokines. Immunomodulatory biological therapies are being evaluated in clinical trials for the management of the systemic inflammatory response and pulmonary complications in patients with advanced stages of COVID‐19. In this review, we summarize the clinical pharmacology considerations in the development of immunomodulatory therapeutic proteins for mitigating the heightened inflammatory response identified in COVID‐19.

Use of biologicals in allergic and type-2 inflammatory diseases during the current COVID-19 pandemic: Position paper of Ärzteverband Deutscher Allergologen (AeDA)A, Deutsche Gesellschaft für Allergologie und Klinische Immunologie (DGAKI)B, Gesellschaft für Pädiatrische Allergologie und Umweltmedizin (GPA)C, Österreichische Gesellschaft für Allergologie und Immunologie (ÖGAI)D, Luxemburgische Gesellschaft für Allergologie und Immunologie (LGAI)E, Österreichische Gesellschaft für Pneumologie (ÖGP)F in co-operation with the German, Austrian, and Swiss ARIA groupsG, and the European Academy of Allergy and Clinical Immunology (EAACI)H

BACKGROUND

Since the beginning of the COVID-19 pandemic, the treatment of patients with allergic and atopy-associated diseases has faced major challenges. Recommendations for "social distancing" and the fear of patients becoming infected during a visit to a medical facility have led to a drastic decrease in personal doctor-patient contacts. This affects both acute care and treatment of the chronically ill. The immune response after SARS-CoV-2 infection is so far only insufficiently understood and could be altered in a favorable or unfavorable way by therapy with monoclonal antibodies. There is currently no evidence for an increased risk of a severe COVID-19 course in allergic patients. Many patients are under ongoing therapy with biologicals that inhibit type 2 immune responses via various mechanisms. There is uncertainty about possible immunological interactions and potential risks of these biologicals in the case of an infection with SARS-CoV-2.

MATERIALS AND METHODS

A selective literature search was carried out in PubMed, Livivo, and the internet to cover the past 10 years (May 2010 - April 2020). Additionally, the current German-language publications were analyzed. Based on these data, the present position paper provides recommendations for the biological treatment of patients with allergic and atopy-associated diseases during the COVID-19 pandemic.

RESULTS

In order to maintain in-office consultation services, a safe treatment environment must be created that is adapted to the pandemic situation. To date, there is a lack of reliable study data on the care for patients with complex respiratory, atopic, and allergic diseases in times of an imminent infection risk from SARS-CoV-2. Type-2-dominant immune reactions, as they are frequently seen in allergic patients, could influence various phases of COVID-19, e.g., by slowing down the immune reactions. Theoretically, this could have an unfavorable effect in the early phase of a SARS-Cov-2 infection, but also a positive effect during a cytokine storm in the later phase of severe courses. However, since there is currently no evidence for this, all data from patients treated with a biological directed against type 2 immune reactions who develop COVID-19 should be collected in registries, and their disease courses documented in order to be able to provide experience-based instructions in the future.

CONCLUSION

The use of biologicals for the treatment of bronchial asthma, atopic dermatitis, chronic rhinosinusitis with nasal polyps, and spontaneous urticaria should be continued as usual in patients without suspected infection or proven SARS-CoV-2 infection. If available, it is recommended to prefer a formulation for self-application and to offer telemedical monitoring. Treatment should aim at the best possible control of difficult-to-control allergic and atopic diseases using adequate rescue and add-on therapy and should avoid the need for systemic glucocorticosteroids. If SARS-CoV-2 infection is proven or reasonably suspected, the therapy should be determined by weighing the benefits and risks individually for the patient in question, and the patient should be involved in the decision-making. It should be kept in mind that the potential effects of biologicals on the immune response in COVID-19 are currently not known. Telemedical offers are particularly desirable for the acute consultation needs of suitable patients.

Managing childhood allergies and immunodeficiencies during respiratory virus epidemics - The 2020 COVID-19 pandemic: A statement from the EAACI-section on pediatrics

While the world is facing an unprecedented pandemic with COVID-19, patients with chronic diseases need special attention and if warranted adaptation of their regular treatment plan. In children, allergy and asthma are among the most prevalent non-communicable chronic diseases, and healthcare providers taking care of these patients need guidance. At the current stage of knowledge, children have less severe symptoms of COVID-19, and severe asthma and immunodeficiency are classified as risk factors. In addition, there is no evidence that currently available asthma and allergy treatments, including antihistamines, corticosteroids, and bronchodilators, increase the risk of severe disease from COVID-19. Most countries affected by COVID-19 have opted for nationwide confinement, which means that communication with the primary clinician is often performed by telemedicine. Optimal disease control of allergic, asthmatic, and immunodeficient children should be sought according to usual treatment guidelines. This statement of the EAACI Section on Pediatrics puts forward six recommendations for the management of childhood allergies and immunodeficiencies based on six underlying facts and existing evidence.