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1.
Am J Cardiol ; 167: 133-138, 2022 03 15.
Article in English | MEDLINE | ID: covidwho-1702670

ABSTRACT

Antecedent use of renin-angiotensin system inhibitors (RASi) prevents clinical deterioration and protects against cardiovascular/thrombotic complications of COVID-19, for indicated patients. Uncertainty exists regarding treatment continuation throughout infection and doing so with concomitant medications. Hence, the purpose of this study is to evaluate the differential effect of RASi continuation in patients hospitalized with COVID-19 according to diuretic use. We used the Coracle registry, which contains data of hospitalized patients with COVID-19 from 4 regions of Italy. We used Firth logistic regression for adult (>50 years) cases with admission on/after February 22, 2020, with a known discharge status as of April 1, 2020. There were 286 patients in this analysis; 100 patients (35.0%) continued RASi and 186 (65%) discontinued. There were 98 patients treated with a diuretic; 51 (52%) of those continued RASi. The in-hospital mortality rates in patients treated with a diuretic and continued versus discontinued RASi were 8% versus 26% (p = 0.0179). There were 188 patients not treated with a diuretic; 49 (26%) of those continued RASi. The in-hospital mortality rates in patients not treated with a diuretic and continued versus discontinued RASi were 16% versus 9% (p = 0.1827). After accounting for age, cardiovascular disease, and laboratory values, continuing RASi decreased the risk of mortality by approximately 77% (odds ratio 0.23, 95% confidence interval 0.06 to 0.95, p = 0.0419) for patients treated with diuretics, but did not alter the risk in patients treated with RASi alone. Continuing RASi in patients concomitantly treated with diuretics was associated with reduced in-hospital mortality.


Subject(s)
Angiotensin Receptor Antagonists/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , COVID-19/therapy , Cardiovascular Diseases/drug therapy , Deprescriptions , Hospital Mortality , Sodium Chloride Symporter Inhibitors/therapeutic use , Sodium Potassium Chloride Symporter Inhibitors/therapeutic use , Aged , Aged, 80 and over , COVID-19/mortality , Drug Therapy, Combination , Female , Hospitalization , Humans , Italy , Logistic Models , Male , Middle Aged , Registries , Renin-Angiotensin System , SARS-CoV-2
2.
J Am Geriatr Soc ; 70(2): 429-438, 2022 02.
Article in English | MEDLINE | ID: covidwho-1483908

ABSTRACT

BACKGROUND: At the height of the COVID-19 pandemic, a large nursing home chain implemented a policy to temporarily hold potentially unnecessary medications. We describe rates of held and discontinued medications after a temporary hold policy of potentially unnecessary or nonessential medications. METHODS: This retrospective cohort study uses electronic health record (EHR) data on 3247 residents of 64 nursing homes operated by a multistate long-term care provider. Medications were documented in the electronic medication administration record. Overall medication held and discontinued incidences are reported. Hierarchical Bayesian modeling is used to determine individual probabilities for medication discontinuation within each facility. RESULTS: In total, 3247 residents had 5297 nonessential medications held. Multivitamins were most likely to be held, followed by histamine-2 receptor antagonists, antihistamines, and statins. At the end of the hold policy, 2897 of 5297 (54%) were permanently discontinued, including probiotics (73%), histamine-2 receptor antagonists (66%), antihistamines (64%), and statins (45%). Demographics, cognitive and functional impairment were similar between residents with medications who were discontinued versus continued. For most medications, more than 50% of the variance in whether medications were discontinued was explained by facility rather than resident-level factors. CONCLUSION: A temporary medication hold policy implemented during the CoVID-19 pandemic led to the deprescribing of a plurality of 'nonessential' medications. This type of organization-wide initiative may be an effective mechanism for altering future prescribing behaviors to reduce the use of unnecessary medications.


Subject(s)
COVID-19 , Deprescriptions , Nursing Homes , Aged , Female , Health Policy , Humans , Long-Term Care , Male , Nursing Homes/trends , Potentially Inappropriate Medication List/statistics & numerical data , Retrospective Studies , United States
3.
Monaldi Arch Chest Dis ; 91(2)2021 May 04.
Article in English | MEDLINE | ID: covidwho-1215533

ABSTRACT

To the Editor COVID-19 (COrona VIrus Disease) patients with cardiovascular (CV) disease, multiple CV risk factors or comorbidities (i.e., arterial hypertension and diabetes) were shown to be more prone to a worse prognosis. SARS-CoV-2 is a still unknown enemy and the role of concomitant cardiovascular therapies has been controversial in the early stages, particularly with regard to Angiotensin-Converting Enzyme inhibitors...


Subject(s)
COVID-19/immunology , Cardiovascular Diseases/prevention & control , Heart Disease Risk Factors , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Hyperlipidemias/drug therapy , Hypolipidemic Agents/therapeutic use , COVID-19/complications , COVID-19/mortality , COVID-19/physiopathology , Cardiovascular Diseases/complications , Cardiovascular Diseases/drug therapy , Deprescriptions , Humans , Hyperlipidemias/complications , Primary Prevention , SARS-CoV-2 , Secondary Prevention
4.
World J Gastroenterol ; 27(11): 1022-1042, 2021 Mar 21.
Article in English | MEDLINE | ID: covidwho-1156170

ABSTRACT

Managing inflammatory bowel disease (IBD) during the coronavirus disease 2019 (COVID-19) pandemic has been a challenge faced by clinicians and their patients, especially concerning whether to proceed with biologics and immunosuppressive agents in the background of a global outbreak of a highly contagious new coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2). The knowledge about the impact of this virus on patients with IBD, although it is still scarce, is rapidly evolving. In particular, concerns surrounding medications' impact for IBD on the risk of acquiring SARS-CoV-2 infection or developing COVID-19, and potentially exacerbate viral replication and the COVID-19 course, are a current thinking of both practicing clinicians and providers caring for patients with IBD. Managing patients with IBD infected with SARS-CoV-2 depends on both the clinical activity of the IBD and the occasional development and severity of COVID-19. In this review, we summarize the current data regarding gastrointestinal involvement by SARS-CoV-2 and pharmacologic and surgical management for IBD concerning this infection, and the COVID-19 impact on both the patient's psychological functioning and endoscopy services, and we concisely summarize the telemedicine roles during the COVID-19 pandemic.


Subject(s)
Biological Products/therapeutic use , COVID-19/complications , Glucocorticoids/therapeutic use , Immunosuppressive Agents/therapeutic use , Inflammatory Bowel Diseases/drug therapy , Telemedicine , Ambulatory Care , Carrier State , Deprescriptions , Disease Management , Endoscopy, Gastrointestinal , Hospitalization , Humans , Immunologic Factors/therapeutic use , Inflammatory Bowel Diseases/complications , Practice Guidelines as Topic , Risk Factors , SARS-CoV-2 , Severity of Illness Index
5.
Arthritis Rheumatol ; 72(8): 1241-1251, 2020 08.
Article in English | MEDLINE | ID: covidwho-602110

ABSTRACT

OBJECTIVE: To provide guidance to rheumatology providers on the management of adult rheumatic disease in the context of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A task force, including 10 rheumatologists and 4 infectious disease specialists from North America, was convened. Clinical questions were collated, and an evidence report was rapidly generated and disseminated. Questions and drafted statements were reviewed and assessed using a modified Delphi process. This included 2 rounds of asynchronous anonymous voting by e-mail and 3 webinars with the entire panel. Task force members voted on agreement with draft statements using a 1-9-point numerical scoring system, and consensus was determined to be low, moderate, or high based on the dispersion of votes. For approval, median votes were required to meet predefined levels of agreement (median values of 7-9, 4-6, and 1-3 defined as agreement, uncertainty, or disagreement, respectively) with either moderate or high levels of consensus. RESULTS: The task force approved 77 initial guidance statements: 36 with moderate and 41 with high consensus. These were combined, resulting in 25 final guidance statements. CONCLUSION: These guidance statements are provided to promote optimal care during the current pandemic. However, given the low level of available evidence and the rapidly evolving literature, this guidance is presented as a "living document," and future updates are anticipated.


Subject(s)
Antirheumatic Agents/therapeutic use , Coronavirus Infections/epidemiology , Glucocorticoids/therapeutic use , Immunosuppressive Agents/therapeutic use , Pneumonia, Viral/epidemiology , Rheumatic Diseases/drug therapy , Adult , Advisory Committees , Angiotensin Receptor Antagonists/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Betacoronavirus , COVID-19 , Coronavirus Infections/complications , Coronavirus Infections/prevention & control , Delivery of Health Care , Delphi Technique , Deprescriptions , Humans , Hydroxychloroquine/therapeutic use , Infection Control , Janus Kinase Inhibitors/therapeutic use , Pandemics/prevention & control , Pneumonia, Viral/complications , Pneumonia, Viral/prevention & control , Rheumatic Diseases/complications , Rheumatology , SARS-CoV-2 , Tumor Necrosis Factor Inhibitors/therapeutic use
7.
Kidney Int ; 98(6): 1549-1558, 2020 12.
Article in English | MEDLINE | ID: covidwho-1023692

ABSTRACT

Notwithstanding the ongoing coronavirus disease-2019 (Covid-19) pandemic, information on its clinical presentation and prognosis in recipients of a kidney transplant remain scanty. The aim of this registry-based observational study was to explore characteristics and clinical outcomes of recipients of kidney transplants included in the French nationwide Registry of Solid Organ Transplant Recipients with Covid-19. Covid-19 was diagnosed in symptomatic patients who had a positive PCR assay for SARS-CoV-2 or having typical lung lesions on imaging. Clinical and laboratory characteristics, management of immunosuppression, treatment for Covid-19, and clinical outcomes (hospitalization, admission to intensive care unit, mechanical ventilation, or death) were recorded. Risk factors for severe disease or death were determined. Of the 279 patients, 243 were admitted to hospital and 36 were managed at home. The median age of hospitalized patients was 61.6 years; most had comorbidities (hypertension, 90.1%; overweight, 63.8%; diabetes, 41.3%; cardiovascular disease, 36.2%). Fever, cough, dyspnea, and diarrhea were the most common symptoms on admission. Laboratory findings revealed mild inflammation frequently accompanied by lymphopenia. Immunosuppressive drugs were generally withdrawn (calcineurin inhibitors: 28.7%; antimetabolites: 70.8%). Treatment was mainly based on hydroxychloroquine (24.7%), antiviral drugs (7.8%), and tocilizumab (5.3%). Severe Covid-19 occurred in 106 patients (46%). Forty-three hospitalized patients died (30-day mortality 22.8%). Multivariable analysis identified overweight, fever, and dyspnea as independent risk factors for severe disease, whereas age over 60 years, cardiovascular disease, and dyspnea were independently associated with mortality. Thus, Covid-19 in recipients of kidney transplants portends a high mortality rate. Proper management of immunosuppression and tailored treatment of this population remain challenging.


Subject(s)
COVID-19/mortality , Kidney Transplantation/mortality , Postoperative Complications/mortality , Registries , Adult , Aged , Aged, 80 and over , COVID-19/complications , COVID-19/therapy , Deprescriptions , Female , France/epidemiology , Humans , Male , Middle Aged , Pandemics/statistics & numerical data , Postoperative Complications/virology , Retrospective Studies , Risk Factors , Young Adult
8.
Adv Chronic Kidney Dis ; 27(5): 383-389, 2020 09.
Article in English | MEDLINE | ID: covidwho-1019900

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2, has led to the death of hundreds of thousands of people worldwide. If infected, older individuals and those with diabetes, hypertension, cardiovascular disease, and compromised immune systems are at higher risk for unfavorable outcomes. These comorbidities are prevalent in patients with kidney disease, hence the significant burden of COVID-19 on kidney transplant programs. Multiple case series of kidney transplant recipients with COVID-19 have shown increased mortality compared to nontransplant patients. To date, we do not have high-level evidence to inform immunosuppression minimization strategies in infected transplant recipients. Most centers however have adopted early antimetabolite withdrawal in addition to other interventions. This review summarizes the published COVID-19 literature as it relates to outcomes and immunosuppression management in kidney transplant recipients. It also discusses challenges pertaining to pretransplant evaluation and wait-listed patients.


Subject(s)
COVID-19/therapy , Graft Rejection/prevention & control , Immunosuppressive Agents/therapeutic use , Kidney Failure, Chronic/surgery , Kidney Transplantation , Telemedicine , COVID-19/mortality , COVID-19/prevention & control , Cross Infection/prevention & control , Delivery of Health Care/methods , Deprescriptions , Humans , Personal Protective Equipment , Physical Distancing , Preoperative Care , SARS-CoV-2 , Waiting Lists
9.
JAMA Intern Med ; 180(12): 1711-1712, 2020 12 01.
Article in English | MEDLINE | ID: covidwho-1001777
10.
Dig Liver Dis ; 53(3): 271-276, 2021 03.
Article in English | MEDLINE | ID: covidwho-987478

ABSTRACT

BACKGROUND: Italy has been one of the most affected countries in the world by COVID-19. There has been increasing concern regarding the impact of COVID-19 on patients with inflammatory bowel disease (IBD), particularly in patients treated with immunosuppressants or biologics. The aim of our study is to understand the incidence of COVID-19 in a large cohort of patients with IBD. Furthermore, we analyzed possible risk factors for infection and severity of COVID-19. METHODS: This was an observational study evaluating the impact of COVID-19 on IBD patients in a single tertiary center. A 23 multiple-choice-question anonymous survey was administered to 1200 patients with IBD between March 10th and June 10th 2020. RESULTS: 1158 questionnaires were analyzed. The majority of patients had Crohn's disease (CD) (60%) and most of them were in clinical remission. Among the 26 patients (2.2%) who tested positive for COVID-19, only 5 (3CD) were on biological treatment and none required hospitalization. Two patients died and were on treatment with mesalazine only. Of the 1158 patients, 521 were on biological therapy, which was discontinued in 85 (16.3%) and delayed in 195 patients (37.4%). A worsening of IBD symptoms was observed in 200 patients on biological therapy (38.4%). Most of these patients, 189 (94.5%), had stopped or delayed biological treatment, while 11 (5.5%) had continued their therapy regularly (p<0.001). CONCLUSIONS: Our data are in line with the current literature and confirm a higher incidence compared to the general population. Biological therapy for IBD seems to not be a risk factor for infection and should not be discontinued in order to avoid IBD relapse.


Subject(s)
COVID-19/epidemiology , Colitis, Ulcerative/epidemiology , Crohn Disease/epidemiology , Adolescent , Adult , Aged , Aged, 80 and over , Antibodies, Monoclonal, Humanized/therapeutic use , Biological Products/therapeutic use , COVID-19/physiopathology , Colitis, Ulcerative/drug therapy , Colitis, Ulcerative/physiopathology , Crohn Disease/drug therapy , Crohn Disease/physiopathology , Deprescriptions , Female , Gastrointestinal Agents/therapeutic use , Hospitalization/statistics & numerical data , Humans , Inflammatory Bowel Diseases/drug therapy , Inflammatory Bowel Diseases/epidemiology , Inflammatory Bowel Diseases/physiopathology , Italy/epidemiology , Male , Mesalamine/therapeutic use , Middle Aged , SARS-CoV-2 , Sulfasalazine/therapeutic use , Tertiary Care Centers , Time-to-Treatment , Tumor Necrosis Factor Inhibitors/therapeutic use , Young Adult
11.
Arthritis Rheumatol ; 73(2): e1-e12, 2021 02.
Article in English | MEDLINE | ID: covidwho-985949

ABSTRACT

OBJECTIVE: To provide guidance to rheumatology providers on the management of adult rheumatic disease in the context of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A task force, including 10 rheumatologists and 4 infectious disease specialists from North America, was convened. Clinical questions were collated, and an evidence report was rapidly generated and disseminated. Questions and drafted statements were reviewed and assessed using a modified Delphi process. This included asynchronous anonymous voting by email and webinars with the entire panel. Task force members voted on agreement with draft statements using a 1-9-point numerical scoring system, and consensus was determined to be low, moderate, or high based on the dispersion of votes. For approval, median votes were required to meet predefined levels of agreement (median values of 7-9, 4-6, and 1-3 defined as agreement, uncertainty, or disagreement, respectively) with either moderate or high levels of consensus. RESULTS: Draft guidance statements approved by the task force have been combined to form final guidance. CONCLUSION: These guidance statements are provided to promote optimal care during the current pandemic. However, given the low level of available evidence and the rapidly evolving literature, this guidance is presented as a "living document," and future updates are anticipated.


Subject(s)
Antirheumatic Agents/therapeutic use , COVID-19/prevention & control , Glucocorticoids/administration & dosage , Immunosuppressive Agents/therapeutic use , Rheumatic Diseases/therapy , Advisory Committees , COVID-19/complications , Consensus , Decision Making, Shared , Delivery of Health Care , Delphi Technique , Deprescriptions , Disease Management , Humans , Patient Education as Topic , Rheumatic Diseases/complications , Rheumatology , SARS-CoV-2 , Societies, Medical
13.
Transpl Infect Dis ; 23(2): e13501, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-949310

ABSTRACT

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might increase the risk of invasive pulmonary aspergillosis (IPA). Although several case reports and small series have been reported in the general population, scarce information is available regarding coronavirus disease 2019 (COVID-19)-associated IPA in the setting of solid organ transplantation. We describe a case of a kidney transplant recipient with severe COVID-19 that was subsequently diagnosed with probable IPA on the basis of the repeated isolation of Aspergillus fumigatus in sputum cultures, repeatedly increased serum (1 â†’ 3)-ß-d-glucan levels, and enlarging cavitary nodules in the CT scan. The evolution was favorable after initiation of isavuconazole and nebulized liposomal amphotericin B combination therapy and the withdrawal of immunosuppression.


Subject(s)
Antifungal Agents/therapeutic use , COVID-19/therapy , Immunosuppressive Agents/adverse effects , Invasive Pulmonary Aspergillosis/drug therapy , Kidney Failure, Chronic/therapy , Kidney Transplantation , Acute Kidney Injury , Administration, Inhalation , Amphotericin B/administration & dosage , Anti-Bacterial Agents/therapeutic use , Antibodies, Monoclonal, Humanized/therapeutic use , Azithromycin/therapeutic use , COVID-19/complications , COVID-19/immunology , Ceftriaxone/therapeutic use , Deprescriptions , Female , Glucocorticoids/adverse effects , Graft Rejection/prevention & control , Humans , Hydroxychloroquine/therapeutic use , Hyperoxaluria, Primary/complications , Hyperoxaluria, Primary/diagnosis , Immunoglobulins, Intravenous/therapeutic use , Immunologic Factors/therapeutic use , Invasive Pulmonary Aspergillosis/complications , Invasive Pulmonary Aspergillosis/diagnostic imaging , Invasive Pulmonary Aspergillosis/immunology , Kidney Failure, Chronic/etiology , Kidney Failure, Chronic/pathology , Middle Aged , Mycophenolic Acid/adverse effects , Nitriles/therapeutic use , Oxygen Inhalation Therapy , Prednisone/adverse effects , Pyridines/therapeutic use , Renal Dialysis , SARS-CoV-2 , Sputum , Tacrolimus/adverse effects , Tomography, X-Ray Computed , Triazoles/therapeutic use
14.
Turk J Med Sci ; 51(2): 428-434, 2021 04 30.
Article in English | MEDLINE | ID: covidwho-922877

ABSTRACT

Background/aim: We aimed to identify clinical settings of renal transplant patients with COVID-19. Materials and methods: In this retrospective study, we included kidney transplant inpatients with laboratory confirmed COVID-19 who had been discharged or had died by October 1st, 2020. Characteristics of the patients, including basal and last outpatient biochemical parameters were recorded. Discontinuation or dosage reduction of immunosuppressives and other treatment information was documented. Results: Twenty patients were included in this study, of whom 18 were discharged and 2 died in hospital. The mean duration of hospitalization and follow-up were 9.7 ± 6.4 days and 4.5 ± 2.0 months, respectively. Fourteen patients (70%) were male and mean age was 48.0 ± 10.3 years. At admission, all had immunosuppression withdrawn and were started on methylprednisolone 16 mg/ day (50%) or dexamethasone (50%). Tacrolimus/m-TOR inhibitors were reduced by 50% and all antimetabolites were discontinued. Hemodialysis was needed for 10% of patients. Acute kidney injury was detected in 25% of the patients. With respect to hospitalization time and complications, there was no significant difference between patients who used dexamethasone and those who did not (P > 0.05). The discontinued immunosuppressives were resumed within 2 to 4 weeks after discharge according to the severity of disease. No rehospitalization or acute rejection was detected during the follow-up of the patients. Conclusion: Renal transplant patients are considered a high risk group for COVID-19. It can be said that discontinuation or reducing dosages of immunosuppressives may be effective and safe in kidney transplant patients.


Subject(s)
COVID-19/physiopathology , Glucocorticoids/therapeutic use , Graft Rejection/prevention & control , Immunocompromised Host , Immunosuppressive Agents/therapeutic use , Kidney Transplantation , Acute Kidney Injury/physiopathology , Acute Kidney Injury/therapy , Adult , COVID-19/immunology , COVID-19/therapy , Deprescriptions , Dexamethasone/therapeutic use , Disease Progression , Everolimus/therapeutic use , Female , Hospital Mortality , Hospitalization , Humans , Length of Stay , Male , Methylprednisolone/therapeutic use , Middle Aged , Mycophenolic Acid/therapeutic use , Renal Dialysis , Respiration, Artificial , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy , Retrospective Studies , SARS-CoV-2 , Sepsis/physiopathology , Tacrolimus/therapeutic use
15.
Expert Opin Pharmacother ; 22(2): 229-240, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-861954

ABSTRACT

INTRODUCTION: Diabetes mellitus is one of the most prevalent comorbidities identified in patients with coronavirus disease 2019 (COVID-19). This article aims to discuss the pharmacotherapeutic considerations for the management of diabetes in hospitalized patients with COVID-19. AREAS COVERED: We discussed various aspects of pharmacotherapeutic management in hospitalized patients with COVID-19: (i) susceptibility and severity of COVID-19 among individuals with diabetes, (ii) glycemic goals for hospitalized patients with COVID-19 and concurrent diabetes, (iii) pharmacological treatment considerations for hospitalized patients with COVID-19 and concurrent diabetes. EXPERT OPINION: The glycemic goals in patients with COVID-19 and concurrent type 1 (T1DM) or type 2 diabetes (T2DM) are to avoid disruption of stable metabolic state, maintain optimal glycemic control, and prevent adverse glycemic events. Patients with T1DM require insulin therapy at all times to prevent ketosis. The management strategies for patients with T2DM include temporary discontinuation of certain oral antidiabetic agents and consideration for insulin therapy. Patients with T2DM who are relatively stable and able to eat regularly may continue with oral antidiabetic agents if glycemic control is satisfactory. Hyperglycemia may develop in patients with systemic corticosteroid treatment and should be managed upon accordingly.


Subject(s)
COVID-19/therapy , Diabetes Mellitus, Type 1/drug therapy , Diabetes Mellitus, Type 2/drug therapy , Hypoglycemic Agents/therapeutic use , Insulin/therapeutic use , Adrenal Cortex Hormones/adverse effects , Blood Glucose/metabolism , COVID-19/complications , Comorbidity , Deprescriptions , Diabetes Mellitus, Type 1/complications , Diabetes Mellitus, Type 1/metabolism , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/metabolism , Dipeptidyl-Peptidase IV Inhibitors/adverse effects , Dipeptidyl-Peptidase IV Inhibitors/therapeutic use , Disease Susceptibility , Glycemic Control , Hospitalization , Humans , Hyperglycemia/chemically induced , Hyperglycemia/drug therapy , Incretins/adverse effects , Incretins/therapeutic use , Metformin/adverse effects , Metformin/therapeutic use , Monitoring, Physiologic , Patient Care Planning , SARS-CoV-2 , Sodium-Glucose Transporter 2 Inhibitors/adverse effects , Sodium-Glucose Transporter 2 Inhibitors/therapeutic use , Thiazolidinediones/adverse effects , Thiazolidinediones/therapeutic use
16.
Prim Care Companion CNS Disord ; 22(4)2020 Jul 16.
Article in English | MEDLINE | ID: covidwho-654929

ABSTRACT

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.


Subject(s)
Coronavirus Infections/therapy , Deprescriptions , Dexmedetomidine/therapeutic use , Emergence Delirium/diagnosis , Hypnotics and Sedatives/therapeutic use , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Substance Withdrawal Syndrome/diagnosis , Adult , Analgesics, Opioid/therapeutic use , Benzodiazepines/therapeutic use , Betacoronavirus , COVID-19 , Emergence Delirium/therapy , Humans , Male , Neurologic Examination , Pandemics , Practice Guidelines as Topic , Propofol/therapeutic use , SARS-CoV-2 , Substance Withdrawal Syndrome/therapy
17.
Clin Rheumatol ; 39(11): 3245-3254, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-746650

ABSTRACT

Rheumatology practice, during Coronavirus Disease 2019 (COVID-19) pandemic, has faced multifaceted challenges. Rheumatologists routinely prescribe immunosuppressant medications to their patients with multisystem autoimmune rheumatic diseases who are concerned about the increased risk of acquiring COVID-19 infection and are anxious to know if they should continue or hold these medications. Rheumatologists are often inundated by calls from their patients and physician colleagues caring for COVID-19 patients in hospitals, about how to manage the immunosuppression. Physicians face the challenging task of keeping up with the most up-to-date information on COVID-19. There are uncertainties about the mode of spread, clinical features, management options as well as long-term complications of COVID-19. Data are rapidly evolving and different studies on treatment options are showing contradictory results. It is known that viral illnesses can trigger a flare-up of underlying rheumatic disease that was previously in remission. To further complicate the scenario, some of the immunosuppressants have shown to have antiviral properties. This has created dilemma in the light of current COVID-19 crisis, as whether to continue or stop the immunosuppressive agents which could be essential to prevent complications of the rheumatic diseases including organ failure but also there is concern about acquiring COVID-19 or developing serious infection. Until we get an effective vaccine, immunosuppressant management for rheumatic diseases as well as other autoimmune diseases and transplants will pose difficult questions. This article is an attempt to review and understand COVID-19 and its impact on the immune system with special emphasis on managing medications used for autoimmune rheumatic diseases. We have provided general guidance about decision making, in regards to the immunosuppressive agents used in rheumatology practice with an understanding that this may change in near future.


Subject(s)
Antirheumatic Agents/therapeutic use , Coronavirus Infections/immunology , Immunosuppressive Agents/therapeutic use , Pneumonia, Viral/immunology , Rheumatic Diseases/drug therapy , Betacoronavirus , COVID-19 , Coronavirus Infections/drug therapy , Cytokine Release Syndrome/immunology , Deprescriptions , Disease Management , Humans , Pandemics , Pneumonia, Viral/drug therapy , SARS-CoV-2
18.
Clin Rheumatol ; 39(11): 3237-3244, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-746145

ABSTRACT

The outbreak of coronavirus in the world has led to an uncertainty about treatment of patients with autoimmune disorders because of their weakened immune system coupled with immunosuppressive agents they take which predisposes them to a host of infections. Data on COVID-19 patients with underlying rheumatological diseases has been emerging mostly in the form of small case series and one global registry. From these data, it seems like our patients, although immunosuppressed, are not particularly susceptible to the coronavirus infection and if infected, do not have significantly worse outcomes than other patients. In fact, drugs like hydroxychloroquine, dexamethasone, and tocilizumab have been studied for treatment of COVID-19. However, this is only preliminary data, and since a few parts of the world are still grappling with the pandemic at its peak, we need to be equipped on how to protect and manage our immunosuppressed patients. Published evidence to guide treatment decisions are lacking and doubts regarding continuation and initiation of immunosuppressants remain. Rheumatoid arthritis (RA) is the most common immune-mediated disorder in COVID-19 patients, and in this review, we discuss how the commonly used drugs in RA alter the patients' susceptibility to this infection. The review also summarizes the recommendations from the major bodies on how to manage this disease in these times. Key Points • Patients on immunosuppressive medications are not found to be at a greatly increased risk of acquiring COVID-19 infection. • Patients doing well on a stable dose of steroid and/or Disease-Modifying Antirheumatic Drugs (DMARDs) should be allowed to continue the same unless they get infected in which case, temporary stoppage of methotrexate and leflunomide may be considered. • Initiation of high-dose steroids, DMARDs, and biologics, if the clinical situation demands so, can be done. • Maintenance biologic therapy for stable patients should be individualized by the treating physician.


Subject(s)
Antirheumatic Agents/therapeutic use , Arthritis, Rheumatoid/drug therapy , Coronavirus Infections , Glucocorticoids/therapeutic use , Pandemics , Pneumonia, Viral , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Betacoronavirus , Biological Products/therapeutic use , COVID-19 , Deprescriptions , Disease Management , Humans , SARS-CoV-2 , Tumor Necrosis Factor Inhibitors/therapeutic use
19.
Eur J Heart Fail ; 22(12): 2205-2215, 2020 12.
Article in English | MEDLINE | ID: covidwho-726285

ABSTRACT

AIMS: Data on the impact of COVID-19 in chronic heart failure (CHF) patients and its potential to trigger acute heart failure (AHF) are lacking. The aim of this work was to study characteristics, cardiovascular outcomes and mortality in patients with confirmed COVID-19 infection and a prior diagnosis of heart failure (HF). Further aims included the identification of predictors and prognostic implications for AHF decompensation during hospital admission and the determination of a potential correlation between the withdrawal of HF guideline-directed medical therapy (GDMT) and worse outcomes during hospitalization. METHODS AND RESULTS: Data for a total of 3080 consecutive patients with confirmed COVID-19 infection and follow-up of at least 30 days were analysed. Patients with a previous history of CHF (n = 152, 4.9%) were more prone to the development of AHF (11.2% vs. 2.1%; P < 0.001) and had higher levels of N-terminal pro brain natriuretic peptide. In addition, patients with previous CHF had higher mortality rates (48.7% vs. 19.0%; P < 0.001). In contrast, 77 patients (2.5%) were diagnosed with AHF, which in the vast majority of cases (77.9%) developed in patients without a history of HF. Arrhythmias during hospital admission and CHF were the main predictors of AHF. Patients developing AHF had significantly higher mortality (46.8% vs. 19.7%; P < 0.001). Finally, the withdrawal of beta-blockers, mineralocorticoid receptor antagonists and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant increase in in-hospital mortality. CONCLUSIONS: Patients with COVID-19 have a significant incidence of AHF, which is associated with very high mortality rates. Moreover, patients with a history of CHF are prone to developing acute decompensation after a COVID-19 diagnosis. The withdrawal of GDMT was associated with higher mortality.


Subject(s)
Arrhythmias, Cardiac/epidemiology , COVID-19/epidemiology , Heart Failure/epidemiology , Hospital Mortality , Acute Disease/epidemiology , Adrenergic beta-Antagonists/therapeutic use , Adult , Age Factors , Aged , Aged, 80 and over , Angiotensin Receptor Antagonists/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , COVID-19/complications , Chronic Disease/epidemiology , Deprescriptions , Disease Progression , Female , Heart Failure/complications , Heart Failure/drug therapy , Heart Failure/physiopathology , Humans , Incidence , Male , Middle Aged , Mineralocorticoid Receptor Antagonists/therapeutic use , Natriuretic Peptide, Brain/blood , Peptide Fragments/blood , Prevalence , Prognosis , Risk Factors , SARS-CoV-2 , Spain/epidemiology
20.
Rheumatol Int ; 40(10): 1599-1611, 2020 Oct.
Article in English | MEDLINE | ID: covidwho-670422

ABSTRACT

The aim of this work is to trace how rheumatologists all over Egypt are approaching the COVID-19 pandemic and what changes it has brought about in the patients' care with special attention to its effect on vulnerable rheumatic disease (RD) patients. This survey further aims to help inform the rheumatology community about the changes in practice during the COVID-19 pandemic. The survey included 26 questions distributed to University staff members across Egypt members of the Egyptian College of Rheumatology (ECR). It takes 5-10 min to fill out. The practice setting of participating rheumatologists included University Teaching Hospitals that are the main rheumatology and clinical immunology service providers for adults and children RD patients. There was an overall agreement across the country in the responses to the survey that took a median time of 7 min to fill in. Potential changes in rheumatology outpatient practice by staff members evolved since the COVID-19 pandemic. None of the university rheumatology staff members has prescribed chloroquine or HCQ to prevent or treat COVID-19 in a non-hospitalized patient who was not previously on it. Twenty-three recommended decrease/avoid NSAIDs if the RD patient had confirmed COVID-19 or symptoms. There is an agreement to the key emerging frontline role of rheumatologists in treating COVID-19. During the pandemic, RD cases requiring admission were dealt with by several modified strategies. The overall agreement among the different university rheumatology departments during such critical situation has provoked the ECR to consider providing provisional guidelines for dealing with RD patients during this global catastrophe.


Subject(s)
Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Antirheumatic Agents/therapeutic use , Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Practice Patterns, Physicians'/statistics & numerical data , Rheumatic Diseases/drug therapy , Rheumatologists/statistics & numerical data , Ambulatory Care/statistics & numerical data , Antirheumatic Agents/supply & distribution , Betacoronavirus , COVID-19 , Coronavirus Infections/drug therapy , Coronavirus Infections/prevention & control , Deprescriptions , Egypt/epidemiology , Humans , Hydroxychloroquine/supply & distribution , Hydroxychloroquine/therapeutic use , Pandemics/prevention & control , Pneumonia, Viral/drug therapy , Pneumonia, Viral/prevention & control , Rheumatology , SARS-CoV-2 , Surveys and Questionnaires
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