Recommendations for allergic disease care during the COVID-19 pandemic


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Maria Patricia S. Abes, MD; Maria Remedios D. Ignacio MD; Nanneth T. Tiu, MD – a group of expert Filipino Allergists bond together as the H & L Allergy Team, whose aim is to give advice, help readers understand and find relief in dealing with common allergic disorders.

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Acute COVID-19 infection and seasonal allergic rhinitis (SAR) share some similarities but also differences.

COVID-19 commonly presents as a flu-like illness with fever and persistent cough as its main symptoms, some patients may also have a runny nose, sore throat, nasal congestion, and aches and pains or diarrhea. Some suffer profound sudden and complete loss of smell and taste. This clinical presentation might be confused with SAR, especially in those new to such symptoms. Cough and fever are the most prominent symptoms of COVID-19, whereas conjunctivitis and itching point to allergic rhinitis (AR) as the diagnosis.

It is very important to keep SAR and other allergic respiratory diseases under the best possible control so as to diminish symptoms like sneezing, rhinorrhoea, and coughing, which could be responsible for viral spread to others via aerosol formation in those who do not realize that they also have COVID-19.

Similarities and differences between seasonal allergic rhinitis and COVID- 19 symptoms (Scadding et al. World Allergy Organization Journal (2020) 13:100124)

ALLERGIC RESPIRATORY DISEASE

Therapy for SAR is best started early and used regularly throughout the relevant pollen season. None of the recommended treatments for SAR are contra-indicated, other than systemic corticosteroids. According to over 90% of experts, there is no contraindication to the use of intranasal corticosteroids (INS). INS do not reduce immunity; in fact, they normalize the structure and function of the nasal mucosa and do not adversely affect mucociliary clearance. However, systemic corticosteroids should be avoided, as they may suppress the human immune system.

Although a viral infection is a major triggering factor of asthma and allergic diseases, asthma is suggested to be not a predisposing condition for coronavirus disease 2019 (COVID-19) infection. However, patients with severe asthma/allergic disease requiring systemic corticosteroids or immunosuppressive agents may be at higher risk of more severe clinical course of this infectious disease. Asthma inhalers should be continued as before and taken regularly, increasing the dose if needed to maintain control in the pollen season. Inhaled corticosteroids (ICS) and ICS combinations with bronchodilators, long acting beta agonists (LABA), are known to protect against virally-induced asthma exacerbations and may be beneficial in COVID-19.

Pediatric allergists should treat patients with asthma, AR or other allergic conditions according to the usual guidelines. During the current pandemic, asthmatic children should continue to receive preventive treatment in order to be under good control.

Patients with more severe asthma and severe chronic rhinosinusitis with nasal polyps who have used biologics (currently available for targeting type 2 inflammation) should continue the treatment while minimizing hospital and face-to-face visits. It is essential to wear protective equipment for the protection of health care workers as well as patients.

Ongoing allergen-specific immunotherapy (AIT) should be continued as long as no COVID-19 infection has been diagnosed. New AIT treatment with subcutaneous immunotherapy (SCIT), is not advised because of the necessity for repeated visits to a physician or hospital; however, the initiation of sublingual immunotherapy (SLIT), which mandates only one initial dose under supervision, should be preferred, or a switch to SLIT from SCIT considered, when there is a suitable alternative to SCIT for the allergen in question.

ATOPIC DERMATITIS

To maintain optimal skincare, moisturizers, topical immunosuppressants and immune-modulating therapies should not be deferred or stopped if needed on the basis of physicians’ judgment to prevent flares of AD.

CHRONIC URTICARIA (CU)

CU may require long-term maintenance therapy because symptoms can last for years in many cases. In healthy subjects without any underlying diseases, CU symptoms are not usually life-threatening, and visiting healthcare facilities may be delayed and rescheduled during this COVID-19 pandemic. Older patients with comorbidities, such as hypertension, diabetes, cardiovascular disease and chronic respiratory disease, are vulnerable to infections and are more cautious in visiting hospitals. However, visiting healthcare facilities would be of some benefit in patients experiencing significant deterioration in the quality of life without regular medication. When patients develop severe symptoms, such as anaphylaxis, angioedema, bronchospasm, dizziness, and hypotension accompanying urticaria, they should visit the emergency department to treat symptoms. Patients are required to follow all the policies for infection control. Physicians should delay the evaluation of the causes of CU and reschedule patient outpatient visits until the pandemic is over.

DRUG ALLERGY

Drug allergy should be immediately treated especially in the presence of symptoms, such as generalized urticaria, angioedema, bronchospasm and hypotension. Epinephrine injection is contemplated in cases of suspected anaphylaxis. Diagnostic procedures, such as drug challenge and drug skin tests, are required to be delayed until the pandemic is over. Drug desensitization is actively considered in patients who need immediate administration of hypersensitivity drugs. In principle, desensitization needs to be performed in the hospital according to the infection control procedure.

TAKE HOME MESSAGES

Early mild COVID-19 symptoms may be confused with or co-occurrent with AR.

Sudden and complete anosmia may be an early sign of COVID-19 infection, differentiating it from AR.

Proper treatment of AR and other allergic respiratory diseases is very important; uncontrolled symptoms may increase the risk of viral dissemination in patients who may have concomitant COVID-19 infection.

Topical and inhaled corticosteroids may even be beneficial or preventative for COVID-19 infection.

Allergen Immunotherapy (AIT) is not immunosuppressive and does not represent a risk factor for more severe COVID-19-induced disease.

It is still uncertain whether COVID-19 increases the risk of aggravating asthma or allergic diseases. Detailed monitoring and optimal treatment with AIT, ICS and biologics need

to be continued in all patients suffering from asthma and allergic diseases. This can be achieved in a safe condition using optimal protective measures.

REFERENCES:

Management of Allergic Patients During the COVID-19 Pandemic in Asia

Allergy Asthma Immunol Res. 2020 Sep;12(5):783-791

Allergic respiratory disease care in the COVID-19 era: A EUFOREA statement

Scadding et al. World Allergy Organization Journal (2020) 13:100124

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