During these early days of the Covid 19 crisis, I’ve spent much of my time on the telephone with my patients. I’m not seeing patients routinely in my office and for the most part, it’s been a matter of verifying that my patients are stable, repeating their prescriptions and planning on a rescheduled appointment when the threat has passed. But much of my time has also been devoted to information sharing – about the coronavirus threat, what to do about social distancing, what to do if they fear that they have acquired the virus and how to manage underlying medical conditions. For me, that means disease-specific instructions for patients with severe asthma, severe COPD and common respiratory diseases. To share some of this more widely, I thought it might be helpful to post some of this on our website.
First, about the virus. It’s probably best thought of as something like the worst influenza we’ve seen in a century or more. It’s highly contagious and seems to be more lethal than any influenza we’ve seen. Like the flu, it poses great risk to the lives of the elderly and those with chronic disease. (But just like the flu, it can surprise us and produce critical illness in those who are relatively young). A couple of big differences is that Covid 19 is brand new and there is no immunity in the population and, as you know, there is no vaccination to reduce the risk of catching Covid 19 – not yet. When someone has this infection, there is no treatment available except supportive measures – reducing fever, maintaining hydration and if breathing is compromised, doctors may help with oxygen and even a ventilator in the ICU if things are really bad. You may have heard of research on various antiviral treatments and other drugs. At the moment, none is available and if any one of them is shown to be helpful, it’s unlikely to be a magic bullet. Viral illnesses are hard to treat and responses to the best antivirals are modest. For example, common estimates suggest that Tamiflu® spares patients with the flu only a day or two of symptoms and only if administered promptly. So…the best solution is to avoid the infection in the first place.
Stay at home.
The term “social distancing” is new to most people and is undefined. I would recommend strongly that to reduce risk to yourself and to “flatten the curve” of rising coronavirus cases, you stay at home unless you are an essential worker or unless you must leave the home for essentials such as a trip to the grocery store or the pharmacy. As I’m writing this for an audience of individuals with a chronic illness, I point out that if your employer hasn’t already sent you home, you could reasonably absent yourself and seek a note from a physician to support your decision. (I expect to be writing quite a few of these). In the end, if your absence from work means that you lose pay, it may be much better to do so rather than suffering the health consequences of this novel viral illness.
Social distancing does not mean simply that you’ve avoided crowds but that you’ve reduced contact with others to a bare minimum. That is, no visits from the grandchildren and no family dinners. Friends and relatives may not understand the need for such isolation yet. You could always say that it’s “doctor’s orders” that are forcing you to be so reclusive.
You don’t need fancy hand sanitizer clipped to your belt. Washing your hands with soap and water is far more effective than a sanitizer. If you’ve been outside your home, please make sure you hand wash. If you have had unavoidable contact with others, hand wash. There is also a suggestion that you try to avoid touching your face that I suppose this is sensible if you can somehow suppress these unconscious gestures. Should you wear a mask? If you have access to a mask, it’s unlikely to be as protective as you’d hope. Masks probably others from your secretions more than they do to protect you from theirs. But of course, do your best to cough or sneeze into your elbow rather than into your hands.
And if I catch this illness?
By now, there are many news outlets and websites describing the symptoms of coronavirus. In general, these are flu-like with high fever, muscle aches and pains and a cough. (But as you’ve also read, mild infections may be present without symptoms and the illness can be spread by such healthy appearing individuals). A screening questionnaire for the coronavirus can be found online:
If you are concerned that you have this new illness, do not rush off to your physician’s office nor to the local emergency room. The recommendation is universal – please phone ahead. If you don’t have the virus, the last thing you want to do is sit in an emergency room where you might be exposed to others who actually do have the virus. If you are infected, sitting in your family physician’s waiting room is not a kindness to others who may also be waiting there for other medical reasons. At the other end of the telephone, a healthcare professional will administer a questionnaire and, if it’s agreed that you have a possible coronavirus infection, you are likely to be directed to a testing centre. There are a growing number of these in Ontario and I’m sure in other provinces as well. (I’m sorry to be so parochial when I’m writing for a national audience). Many of these test centres are adjacent to large hospitals. If you are directed there, you will have a swab collected from your nasal passages so that you and your physician can determine what to do next.
What happens if your test is positive? In general, if your breathing is reasonable and your case appears to be mild, you are amongst the “walking wounded” and might be sent home to convalesce. If this happens to you, make sure that your healthcare providers are aware of any underlying medical diagnoses and who is at home to help you. If they know that you suffer from, for example, emphysema, they might choose to monitor you more closely or admit you. If your breathing remains reasonable and you can ride out the storm, that’s great.
And what about my respiratory illness?
Take your medications as prescribed
A common question I’ve heard from my patients and read online is that somehow inhaled medications will predispose them to catching the coronavirus and should be stopped. The concern seems to be about inhaled steroids. There is no evidence that inhaled steroids increase your risk of acquiring coronavirus and if they’ve been prescribed as an important part of your treatment, you should not skip them. Doing so could increase your respiratory problems and pose a greater hazard to your health if you are actually exposed to coronavirus. Make sure you’ve been in touch with a prescribing physician so that your medications are available in adequate quantities. Over the next few weeks it may be difficult to reach your physician in a timely fashion and you don’t want to be calling because your medication is running out tomorrow. By the way, your regular inhaled medication should be dispensed in adequate amounts. I see little or no need to dispense inhalers on a monthly schedule – that just makes running out and missing doses more likely. In the midst of this crisis, the additional issue is the need to avoid unnecessary trips outside the home and that includes unnecessarily frequent trips to the pharmacy.
Have your action plan medications on hand
At the end of routine visits to my office, I try to make sure that all of my patients with chronic lung conditions have an action plan. That is, they need to know how to recognize a worsening of their condition and what steps to take in response. This also includes access to action plan medications. For someone with severe asthma, this often means a prescription for prednisone. For my patients with COPD, this is often dual prescriptions for antibiotic and prednisone. For someone with bronchiectasis, this may mean an antibiotic is chosen as the best available for the bacteria usually found in that patient’s sputum. It’s not that I want to keep people away from their doctors when they’re sick; I just want to make sure that treatment of any worsening is undertaken promptly. Early treatment tends to shorten the “chest cold” or what doctors call an exacerbation. I’m asked often if the prescription should be filled immediately and I always say “yes”. That way, if you do feel under the weather, you won’t be forced to make the trek to the drugstore to follow through on the action plan. During the current coronavirus crisis, access to a physician and access to the drugstore may be problematic so make sure you have action plan medications. If you haven’t discussed this with your doctor, please do so now.
What about my injections?
Some of you may be receiving scheduled biologic therapy for asthma or intravenous immune globulin for an immune deficiency. Don’t stop these important treatments. Medicines like Nucala (mepolizumab), Fasenra (benralizumab), Xolair (omalizumab) and Cinqair (reslizumab) are very important for keeping vulnerable asthmatic breathing passages stable. There is no evidence that using them impairs the ability to fight common viruses like coronavirus and stopping them suddenly could provoke a severe worsening of asthma.
Is it safe to go to an infusion/injection centre once per week? I can’t offer a blanket answer. Many of you will be receiving your injection treatment in an Innomar Clinic while others may be receiving such treatment elsewhere. I’ll assume that all of these health care facilities will have some form of screening in place; you’ll want to check your specific location. Are they screening visitors and staff rigorously and are they spacing appointments to create that “social distancing” we talked about? A few folks may be receiving home injections and similar questions apply. Is the visiting nurse being screened and monitored? How will the risk of cross contamination between patients be minimized? I’ve found nothing on the Innomar website but an indirect communication tells me that Innomar has implemented screening at its facilities although I’ve not confirmed the specifics of the screening and whether or not patient appointments allow for social distancing. There is no information about the monitoring of home infusion nurses.
Inquire about self-administration of your treatment. It’s being developed for all biologic therapies and at least one of the biologic therapies for asthma is approved for self-administration. This allows you to avoid health care facilities and risking exposure to someone who may be carrying the virus. At the moment, this is officially available for just one asthma biologic (Nucala) but the current crisis could be one way to speed approval of others.
I hope these thoughts are helpful. I’ll try to update information as it becomes available. If you have questions, I can’t promise that I’ll answer them quickly (and I’ll avoid specific medical advice) but pass your questions along through the website and I’ll do my best.