Covid ICYMI

As might be expected, the “EULAR [European League Against Rheumatism] provisional recommendations for the management of rheumatic and musculoskeletal diseases [RMDs] in the context of SARS-CoV-2” concur with much of the guidance already released on how best to manage patients during the current pandemic.

Highlights of the five overarching principles are that, contrary to earlier expectations, “there is no indication that patients with RMDs have an additional, or have a higher, risk of contracting the virus, or that they fare a worse course” than the general population, said the task force convener Robert Landewé, MD, PhD, professor of rheumatology at the University of Amsterdam.

“The second pertinent highlight is that, when it comes to managerial discussions, whether or not to stop or to start treatment for RMDs, rheumatologists should definitely be involved,” Dr. Landewé said during a live session at the annual European Congress of Rheumatology, held online this year due to COVID-19. “In practice, something that happens very often is that immunosuppressive drugs are stopped by medical specialists involved in the care of COVID but without any expertise in treating patients with rheumatic diseases. We should try to avoid that situation.”

The third highlight, something many rheumatologists may already be well aware of, is that rheumatology drugs are being used to treat COVID-19 patients without RMDs and a shortage of disease-modifying antirheumatic drugs (DMARDs) agents is a real possibility. As such, the fifth overarching highlight states that the availability of both synthetic and biologic DMARDs is “a delicate societal responsibility” and that “the off-label use of DMARDs in COVID-19 outside the context of clinical trials should be discouraged.”

The EULAR recommendation are now published online in Annals of the Rheumatic Diseases and they are “what you could call an unprecedented set of recommendations,” Dr. Landewé said. “We have never done this before,” he added, referring to the speed and way in which they had to be put together, remotely, and with little scientific evidence currently available. “Three months ago we hadn’t even heard about the virus.”

From the first patient being identified in the Hubei province of China in November 2019, to the first U.S. patient in the state of Washington on Jan. 20, 2020, and to the first European patient identified a little over 10 days later, the COVID-19 pandemic has taken the world by storm. It was only declared a pandemic on March 11, 2020, however, and Dr. Landewé noted that the response to the pandemic had been very variable – some countries locking down their borders early, while others took their time to make an appropriate response, if at all.

The rheumatology community was particularly concerned, Dr. Landewé said, because people with autoimmune diseases who were taking immunosuppressant drugs might be at higher risk for becoming infected with SARS-CoV-2, and may be at higher risk than others for a worse disease course. Thankfully, that seems not to be the case according to data that are emerging from new registries that have been set up, including EULAR’s own COVID-19 registry.

There are 13 recommendations that cover 4 themes: general measures and prevention of SARS-CoV-2 infection; the management of RMD patients during the pandemic; the management of RMD patients who have COVID-19; and the prevention of other pulmonary infections in RMD patients.

Highlighting the first three general recommendations, Dr. Landewé said: “Follow the regular guidelines in your country; if a patient with RMD does not have symptoms of COVID-19, simply continue RMD treatments,” albeit with a couple of exceptions.

The next four recommendation highlights are to avoid visits to the hospital or to the office; use remote monitoring via the telephone, for example; and if visits cannot be avoided, then take appropriate precautions. Finally, if you suspect a patient has COVID-19, do a test.

If patients test positive, then the next four recommendations cover what to do, such as continuing use of RMD treatments, but in the case of glucocorticoids this should be the lowest possible dose necessary. There is no consensus on what to do in cases of mild symptoms; the recommendation is to “decide on a case-by-case basis,” said Dr. Landewé. If a patient’s symptoms worsen, then “seek expert advice immediately and follow local treatment recommendations. The rheumatologist is not the expert to treat COVID-19,” he added. That responsibility lies with the pulmonologist, infectious disease specialist, or maybe the intensive care specialist, depending on local situations.

On the whole, the EULAR recommendations are pretty similar to those already released by the American College of Rheumatology, said Ted Mikuls, MD, of the University of Nebraska Medical Center, Omaha. The ACR recommendations are “slightly more prescriptive”, he suggested, with 25 final guidance statements. For example, general statements focused not only on the use of glucocorticoids, but also other medicines, such as antihypertensives.

“There’s really not a [lot of], I would say, major differences in the two efforts and that’s ... somewhat reassuring that we’re approaching the unknown from very different parts of the world, and driving in a very similar place,” commented Dr. Mikuls, who is a member of the ACR COVID-19 recommendations task force.

“I think one of the very important similarities that I would highlight is that, in the absence of known exposure, in the absence of COVID-19 infection, our panel felt very strongly about the importance of continuing rheumatic disease treatments,” Dr. Mikuls observed. The ACR guidelines also touch upon societal perspectives, including “some statements that were made very specific to lupus, and the use of antimalarials, given supply chain issues that we have encountered.”

Dr. Mikuls also said that the American recommendations emphasized that “you really have to manage active inflammatory rheumatic disease. Even in the context of the COVID-19 pandemic, given what we saw as the potential risk of unchecked inflammation and unchecked rheumatic disease.”

One notable difference, however, is that the European recommendations advise on immunizations and pneumonia prophylaxis, saying that all patients without COVID-19 symptoms should make sure they are up to date with any recommended vaccinations, “with a particular focus on pneumococcal and influenza vaccinations,” Dr. Landewé said.

Another difference is that the ACR recommendations are a living document and could potentially be updated monthly if the evidence arrives to allow that. In that sense, the American guidance is more agile, with EULAR expecting to update its recommendations every 3 months.

“The current evidence is extremely sparse and fragmented,” Dr. Landewé said. “We, as a task force are essentially flying blindly. We also have to cover many jurisdictions within Europe, with many conflicting opinions. So the last word to say is that updates are truly necessary, but we have to wait a while.”

SOURCE: Landewé RB et al. Ann Rheum Dis. 2020 Jun 5. doi: 10.1136/annrheumdis-2020-217877.

As might be expected, the “EULAR [European League Against Rheumatism] provisional recommendations for the management of rheumatic and musculoskeletal diseases [RMDs] in the context of SARS-CoV-2” concur with much of the guidance already released on how best to manage patients during the current pandemic.

Highlights of the five overarching principles are that, contrary to earlier expectations, “there is no indication that patients with RMDs have an additional, or have a higher, risk of contracting the virus, or that they fare a worse course” than the general population, said the task force convener Robert Landewé, MD, PhD, professor of rheumatology at the University of Amsterdam.

“The second pertinent highlight is that, when it comes to managerial discussions, whether or not to stop or to start treatment for RMDs, rheumatologists should definitely be involved,” Dr. Landewé said during a live session at the annual European Congress of Rheumatology, held online this year due to COVID-19. “In practice, something that happens very often is that immunosuppressive drugs are stopped by medical specialists involved in the care of COVID but without any expertise in treating patients with rheumatic diseases. We should try to avoid that situation.”

The third highlight, something many rheumatologists may already be well aware of, is that rheumatology drugs are being used to treat COVID-19 patients without RMDs and a shortage of disease-modifying antirheumatic drugs (DMARDs) agents is a real possibility. As such, the fifth overarching highlight states that the availability of both synthetic and biologic DMARDs is “a delicate societal responsibility” and that “the off-label use of DMARDs in COVID-19 outside the context of clinical trials should be discouraged.”

The EULAR recommendation are now published online in Annals of the Rheumatic Diseases and they are “what you could call an unprecedented set of recommendations,” Dr. Landewé said. “We have never done this before,” he added, referring to the speed and way in which they had to be put together, remotely, and with little scientific evidence currently available. “Three months ago we hadn’t even heard about the virus.”

From the first patient being identified in the Hubei province of China in November 2019, to the first U.S. patient in the state of Washington on Jan. 20, 2020, and to the first European patient identified a little over 10 days later, the COVID-19 pandemic has taken the world by storm. It was only declared a pandemic on March 11, 2020, however, and Dr. Landewé noted that the response to the pandemic had been very variable – some countries locking down their borders early, while others took their time to make an appropriate response, if at all.

The rheumatology community was particularly concerned, Dr. Landewé said, because people with autoimmune diseases who were taking immunosuppressant drugs might be at higher risk for becoming infected with SARS-CoV-2, and may be at higher risk than others for a worse disease course. Thankfully, that seems not to be the case according to data that are emerging from new registries that have been set up, including EULAR’s own COVID-19 registry.

There are 13 recommendations that cover 4 themes: general measures and prevention of SARS-CoV-2 infection; the management of RMD patients during the pandemic; the management of RMD patients who have COVID-19; and the prevention of other pulmonary infections in RMD patients.

Highlighting the first three general recommendations, Dr. Landewé said: “Follow the regular guidelines in your country; if a patient with RMD does not have symptoms of COVID-19, simply continue RMD treatments,” albeit with a couple of exceptions.

The next four recommendation highlights are to avoid visits to the hospital or to the office; use remote monitoring via the telephone, for example; and if visits cannot be avoided, then take appropriate precautions. Finally, if you suspect a patient has COVID-19, do a test.

If patients test positive, then the next four recommendations cover what to do, such as continuing use of RMD treatments, but in the case of glucocorticoids this should be the lowest possible dose necessary. There is no consensus on what to do in cases of mild symptoms; the recommendation is to “decide on a case-by-case basis,” said Dr. Landewé. If a patient’s symptoms worsen, then “seek expert advice immediately and follow local treatment recommendations. The rheumatologist is not the expert to treat COVID-19,” he added. That responsibility lies with the pulmonologist, infectious disease specialist, or maybe the intensive care specialist, depending on local situations.

On the whole, the EULAR recommendations are pretty similar to those already released by the American College of Rheumatology, said Ted Mikuls, MD, of the University of Nebraska Medical Center, Omaha. The ACR recommendations are “slightly more prescriptive”, he suggested, with 25 final guidance statements. For example, general statements focused not only on the use of glucocorticoids, but also other medicines, such as antihypertensives.

“There’s really not a [lot of], I would say, major differences in the two efforts and that’s ... somewhat reassuring that we’re approaching the unknown from very different parts of the world, and driving in a very similar place,” commented Dr. Mikuls, who is a member of the ACR COVID-19 recommendations task force.

“I think one of the very important similarities that I would highlight is that, in the absence of known exposure, in the absence of COVID-19 infection, our panel felt very strongly about the importance of continuing rheumatic disease treatments,” Dr. Mikuls observed. The ACR guidelines also touch upon societal perspectives, including “some statements that were made very specific to lupus, and the use of antimalarials, given supply chain issues that we have encountered.”

Dr. Mikuls also said that the American recommendations emphasized that “you really have to manage active inflammatory rheumatic disease. Even in the context of the COVID-19 pandemic, given what we saw as the potential risk of unchecked inflammation and unchecked rheumatic disease.”

One notable difference, however, is that the European recommendations advise on immunizations and pneumonia prophylaxis, saying that all patients without COVID-19 symptoms should make sure they are up to date with any recommended vaccinations, “with a particular focus on pneumococcal and influenza vaccinations,” Dr. Landewé said.

Another difference is that the ACR recommendations are a living document and could potentially be updated monthly if the evidence arrives to allow that. In that sense, the American guidance is more agile, with EULAR expecting to update its recommendations every 3 months.

“The current evidence is extremely sparse and fragmented,” Dr. Landewé said. “We, as a task force are essentially flying blindly. We also have to cover many jurisdictions within Europe, with many conflicting opinions. So the last word to say is that updates are truly necessary, but we have to wait a while.”

SOURCE: Landewé RB et al. Ann Rheum Dis. 2020 Jun 5. doi: 10.1136/annrheumdis-2020-217877.

As might be expected, the “EULAR [European League Against Rheumatism] provisional recommendations for the management of rheumatic and musculoskeletal diseases [RMDs] in the context of SARS-CoV-2” concur with much of the guidance already released on how best to manage patients during the current pandemic.

Highlights of the five overarching principles are that, contrary to earlier expectations, “there is no indication that patients with RMDs have an additional, or have a higher, risk of contracting the virus, or that they fare a worse course” than the general population, said the task force convener Robert Landewé, MD, PhD, professor of rheumatology at the University of Amsterdam.

“The second pertinent highlight is that, when it comes to managerial discussions, whether or not to stop or to start treatment for RMDs, rheumatologists should definitely be involved,” Dr. Landewé said during a live session at the annual European Congress of Rheumatology, held online this year due to COVID-19. “In practice, something that happens very often is that immunosuppressive drugs are stopped by medical specialists involved in the care of COVID but without any expertise in treating patients with rheumatic diseases. We should try to avoid that situation.”

The third highlight, something many rheumatologists may already be well aware of, is that rheumatology drugs are being used to treat COVID-19 patients without RMDs and a shortage of disease-modifying antirheumatic drugs (DMARDs) agents is a real possibility. As such, the fifth overarching highlight states that the availability of both synthetic and biologic DMARDs is “a delicate societal responsibility” and that “the off-label use of DMARDs in COVID-19 outside the context of clinical trials should be discouraged.”

The EULAR recommendation are now published online in Annals of the Rheumatic Diseases and they are “what you could call an unprecedented set of recommendations,” Dr. Landewé said. “We have never done this before,” he added, referring to the speed and way in which they had to be put together, remotely, and with little scientific evidence currently available. “Three months ago we hadn’t even heard about the virus.”

From the first patient being identified in the Hubei province of China in November 2019, to the first U.S. patient in the state of Washington on Jan. 20, 2020, and to the first European patient identified a little over 10 days later, the COVID-19 pandemic has taken the world by storm. It was only declared a pandemic on March 11, 2020, however, and Dr. Landewé noted that the response to the pandemic had been very variable – some countries locking down their borders early, while others took their time to make an appropriate response, if at all.

The rheumatology community was particularly concerned, Dr. Landewé said, because people with autoimmune diseases who were taking immunosuppressant drugs might be at higher risk for becoming infected with SARS-CoV-2, and may be at higher risk than others for a worse disease course. Thankfully, that seems not to be the case according to data that are emerging from new registries that have been set up, including EULAR’s own COVID-19 registry.

There are 13 recommendations that cover 4 themes: general measures and prevention of SARS-CoV-2 infection; the management of RMD patients during the pandemic; the management of RMD patients who have COVID-19; and the prevention of other pulmonary infections in RMD patients.

Highlighting the first three general recommendations, Dr. Landewé said: “Follow the regular guidelines in your country; if a patient with RMD does not have symptoms of COVID-19, simply continue RMD treatments,” albeit with a couple of exceptions.

The next four recommendation highlights are to avoid visits to the hospital or to the office; use remote monitoring via the telephone, for example; and if visits cannot be avoided, then take appropriate precautions. Finally, if you suspect a patient has COVID-19, do a test.

If patients test positive, then the next four recommendations cover what to do, such as continuing use of RMD treatments, but in the case of glucocorticoids this should be the lowest possible dose necessary. There is no consensus on what to do in cases of mild symptoms; the recommendation is to “decide on a case-by-case basis,” said Dr. Landewé. If a patient’s symptoms worsen, then “seek expert advice immediately and follow local treatment recommendations. The rheumatologist is not the expert to treat COVID-19,” he added. That responsibility lies with the pulmonologist, infectious disease specialist, or maybe the intensive care specialist, depending on local situations.

On the whole, the EULAR recommendations are pretty similar to those already released by the American College of Rheumatology, said Ted Mikuls, MD, of the University of Nebraska Medical Center, Omaha. The ACR recommendations are “slightly more prescriptive”, he suggested, with 25 final guidance statements. For example, general statements focused not only on the use of glucocorticoids, but also other medicines, such as antihypertensives.

“There’s really not a [lot of], I would say, major differences in the two efforts and that’s ... somewhat reassuring that we’re approaching the unknown from very different parts of the world, and driving in a very similar place,” commented Dr. Mikuls, who is a member of the ACR COVID-19 recommendations task force.

“I think one of the very important similarities that I would highlight is that, in the absence of known exposure, in the absence of COVID-19 infection, our panel felt very strongly about the importance of continuing rheumatic disease treatments,” Dr. Mikuls observed. The ACR guidelines also touch upon societal perspectives, including “some statements that were made very specific to lupus, and the use of antimalarials, given supply chain issues that we have encountered.”

Dr. Mikuls also said that the American recommendations emphasized that “you really have to manage active inflammatory rheumatic disease. Even in the context of the COVID-19 pandemic, given what we saw as the potential risk of unchecked inflammation and unchecked rheumatic disease.”

One notable difference, however, is that the European recommendations advise on immunizations and pneumonia prophylaxis, saying that all patients without COVID-19 symptoms should make sure they are up to date with any recommended vaccinations, “with a particular focus on pneumococcal and influenza vaccinations,” Dr. Landewé said.

Another difference is that the ACR recommendations are a living document and could potentially be updated monthly if the evidence arrives to allow that. In that sense, the American guidance is more agile, with EULAR expecting to update its recommendations every 3 months.

“The current evidence is extremely sparse and fragmented,” Dr. Landewé said. “We, as a task force are essentially flying blindly. We also have to cover many jurisdictions within Europe, with many conflicting opinions. So the last word to say is that updates are truly necessary, but we have to wait a while.”

SOURCE: Landewé RB et al. Ann Rheum Dis. 2020 Jun 5. doi: 10.1136/annrheumdis-2020-217877.

It is clear that the coronavirus 2019 disease (COVID-19) pandemic is one of the most extraordinary epochs of our professional and personal lives. Besides the challenges to the techniques and technologies of care for this illness, we are seeing challenges to the fundamentals of health care, both to the systems whereby it is delivered, and to the ethical principles that guide that delivery. There is unprecedented relevance of certain ethical issues in the practice of medicine, many of which have previously been discussed in classrooms and textbooks, but now are at play in daily practice, particularly at the frontlines of the war against COVID-19.¹ In this article, I highlight several ethical dilemmas that are salient to these unique times. Some of the most compelling issues can be sorted into 2 clearly overlapping domains: triage ethics and equity ethics.

Triage ethics

In the areas most greatly affected by the COVID-19 pandemic, scarcity of treatment resources, such as ventilators, is a legitimate concern. French surgeon Dominique Jean Larry was the first to establish medical sorting protocols in the context of the battles of the Napoleonic wars, for which he used the French word triage, meaning “sorting.”² He articulated 3 prognostic categories: 1) those who would die even with treatment, 2) those who would live without treatment, and 3) those who would die unless treated. Triage decisions arise in the context of insufficient resources, particularly space, staff, and supplies. Although usually identified with disasters, these decisions can arise in other contexts where personnel or technological resources are inadequate. Indeed, one of the first modern incarnations of triage ethics in American civilian life was in the early days of hemodialysis, when so-called “God committees” made complex decisions about which patients would be able to use this new, rare technology.³

Two fundamental moral constructs undergird medical ethics: deontological and utilitarian. The former, in which most clinicians traffic in ordinary practice, is driven by principles or moral rules such as the sanctity of life, the rule of fairness, and the principle of autonomy.⁴ They apply primarily in the context of treating an individual patient. The utilitarian way of reasoning is not as familiar to clinicians. It is focused on the broader context, the common good, the health of the group. It asks to calculate “the greatest good for the greatest number” as a means of navigating ethical dilemmas.⁵ The utilitarian perspective is far more familiar to policymakers, health care administrators, and public health professionals. It tends to be anathema to clinicians. However, disasters such as the COVID-19 pandemic ask some clinicians, particularly inpatient physicians, to shift from their usual deontological perspective to a utilitarian one, because triage ethics fundamentally draw on utilitarian reasoning. This can be quite anguishing to clinicians who typically work with individual patients in settings of more adequate, if not abundant, resources. What may feel wrong in a deontological mode can be seen as ethically right in a utilitarian framework.

The Table compares and contrasts these 2 paradigms and how they manifest in the clinical trenches, in a protracted health care crisis with limited resources.

The COVID-19 crisis has produced an unprecedented and extended exposure of clinicians to triage situations in the face of limited resources such as ventilators, personnel, personal protective equipment, etc.⁶ Numerous possible approaches to deploying limited supplies are being considered. On what basis should such decisions be made? How can fairness be optimally manifest? Some possibilities include:

• first come, first served
• youngest first
• lottery
• short-term survivability
• long-term prognosis for quality of life
• value of a patient to the lives of others (eg, parents, health care workers, vaccine researchers).

One particularly interesting exploration of these questions was done in Maryland and reported in the “Maryland Framework for the Allocation of Scarce Life-sustaining Medical Resources in a Catastrophic Public Health Emergency.”⁷ This was the product of a multi-year consultation, ending in 2017, with several constituencies, including clinicians, politicians, hospital administrators, and members of the public brainstorming about approaches to allocating a hypothetical scarcity of ventilators. Interestingly, there was one broad consensus among these groups: a ventilator should not be withdrawn from a patient already using it to give to a “better” candidate who comes along later.

Some institutions have developed a method of making triage decisions that takes such decisions out of the hands of individual clinicians and instead assigns them to specialized “triage teams” made up of ethicists and clinicians experienced in critical care, to develop more distance from the emotions at the bedside. To minimize bias, such teams are often insulated from getting personal information about the patient, and receive only acute clinical information.⁸

Continue to: The pros and cons of these approaches...

The pros and cons of these approaches and the underlying ethical reasoning is beyond the scope of this overview. Policy documents from different states, regions, nations, and institutions have various approaches to making these choices. Presently, there is no coherent national or international agreement on triage ethics.⁹ It is important, however, that there be transparency in whatever approach an institution adopts for triage decisions.

Equity ethics

Though the equitable distribution of health care delivery has long been a concern, this problem has become magnified by the COVID-19 crisis. Race, sex, age, socioeconomic class, and type of illness have all been perennial sources of division between those who have better or worse access to health care and its outcomes. All of these distinctions have created differentials in rates of cases, hospitalizations, and deaths in the COVID-19 pandemic.¹⁰

The shifting of acute health care facilities to mostly COVID-19–related treatment, and postponing less critical and more “elective” care, creates a divide based on illness type. Many facilities have stopped taking admissions for other kinds of cases. This is particularly relevant to psychiatric units, many of which have had to decrease their bed capacities to make all rooms private, and limit their usual treatments offered to inpatients.¹¹ Many long-term units, such as at state hospitals, are closing to new admissions. Many day hospitals and intensive outpatient programs remain closed, not even shifting to telehealth. In areas most affected by COVID-19, some institutions have closed psychiatric wards and reallocated psychiatrists to cover some of the medical units. So the availability of the more intensive, institutionally-based levels of care is significantly reduced, particularly for psychiatric patients.¹² These patients already are a disadvantaged population in the distribution of health care resources, and the care of individuals with serious mental illness is more likely to be seen as “nonessential” in this time of suddenly scarcer institutional resources.

One of the cherished ethical values in health care is autonomy, and in a deontological triage environment, honoring patient autonomy is carefully and tenderly administered. However, in a utilitarian-driven triage environment, considerations of the common good can trump autonomy, even in subtle ways that create inequities. Clinicians have been advised to have more frank conversations with patients, particularly those with chronic illnesses, stepping up initiatives to make advanced directives during this crisis, explicitly reminding patients that there may not be enough ventilators for all who need one.¹³ Some have argued that such physician-initiated conversations can be inherently coercive, making these decisions not as autonomous as it may appear, similar to physicians suggesting medical euthanasia as an option.¹⁴ Interestingly, some jurisdictions that offer euthanasia have been suspending such services during the COVID-19 crisis.¹⁵ Some hospitals have even wrestled with the possibility that all COVID-19 admissions should be considered “do not resuscitate,” especially because cardiopulmonary resuscitation significantly elevates the risks of viral exposure for the treatment team.^16,17 A more explicit example of how current standards protecting patient autonomy may be challenged is patients who are admitted involuntarily to a psychiatric unit. These are patients whose presumptively impaired autonomy is already being overridden by the involuntary nature of the admission. If a psychiatric unit requires admissions to be COVID-19–negative, and if patients refuse COVID-19 testing, should the testing be forced upon them to protect the entire milieu?

Many ethicists are highlighting the embedded equity bias known as “ableism” inherent in triage decisions—implicitly disfavoring resources for patients with COVID-19 who are already physically or intellectually disabled, chronically ill, aged, homeless, psychosocially low functioning, etc.¹⁸ Without explicit protections for individuals who are chronically disabled, triage decisions unguided by policy safeguards may reflexively favor the more “abled.” This bias towards the more abled is often inherent in how difficult it is to access health care. It can also be manifested in bedside triage decisions made in the moment by individual clinicians. Many disability rights advocates have been sounding this alarm during the COVID-19 crisis.¹⁹

Continue to: A special circumstance of equity...

A special circumstance of equity is arising during this ongoing pandemic—the possibility of treating health care workers as a privileged class. Unlike typical disasters, where health care workers come in afterwards, and therefore are in relatively less danger, pandemics create particularly high risks of danger for such individuals, with repeated exposure to the virus. They are both responders and potential victims. Should they have higher priority for ventilators, vaccines, funding, etc?⁶ This is a more robust degree of compensatory justice than merely giving appreciation. Giving health care workers such advantages may seem intuitively appealing, but perhaps professionalism and the self-obligation of duty mitigates such claims.²⁰

A unique opportunity

The magnitude and pervasiveness of this pandemic crisis is unique in our lifetimes, as both professionals and as citizens. In the crucible of this extraordinary time, these and other medical ethics dilemmas burn hotter than ever before. Different societies and institutions may come up with different answers, based on their cultures and values. It is important, however, that the venerable ethos of medical ethics, which has evolved through the millennia, codified in oaths, codes, and scholarship, can be a compass at the bedside and in the meetings of legislatures, leaders, and policymakers. Perhaps we can emerge from this time with more clarity about how to balance the preciousness of individual rights with the needs of the common good.

Bottom Line

The coronavirus disease 2019 (COVID-19) pandemic has brought increased attention to triage ethics and equity ethics. There is no coherent national or international agreement on how to best deploy limited supplies such as ventilators and personal protective equipment. Although the equitable distribution of health care delivery has long been a concern, this problem has become magnified by COVID-19. Clinicians may be asked to view health care through the less familiar lens of the common good, as opposed to focusing strictly on an individual patient.

Related Resources

• Johns Hopkins Berman Institute of Bioethics. Coronavirus ethics and policy insights and resources. https://bioethics.jhu.edu/research-and-outreach/covid-19-bioethics-expert-insights/.
• Daugherty-Biddison L, Gwon H, Regenberg A, et al. Maryland framework for the allocation of scarce lifesustaining medical resources in a catastrophic public health emergency. www.law.umaryland.edu/media/SOL/pdfs/Programs/Health-Law/MHECN/ASR%20Framework_Final.pdf.

It is clear that the coronavirus 2019 disease (COVID-19) pandemic is one of the most extraordinary epochs of our professional and personal lives. Besides the challenges to the techniques and technologies of care for this illness, we are seeing challenges to the fundamentals of health care, both to the systems whereby it is delivered, and to the ethical principles that guide that delivery. There is unprecedented relevance of certain ethical issues in the practice of medicine, many of which have previously been discussed in classrooms and textbooks, but now are at play in daily practice, particularly at the frontlines of the war against COVID-19.¹ In this article, I highlight several ethical dilemmas that are salient to these unique times. Some of the most compelling issues can be sorted into 2 clearly overlapping domains: triage ethics and equity ethics.

Triage ethics

In the areas most greatly affected by the COVID-19 pandemic, scarcity of treatment resources, such as ventilators, is a legitimate concern. French surgeon Dominique Jean Larry was the first to establish medical sorting protocols in the context of the battles of the Napoleonic wars, for which he used the French word triage, meaning “sorting.”² He articulated 3 prognostic categories: 1) those who would die even with treatment, 2) those who would live without treatment, and 3) those who would die unless treated. Triage decisions arise in the context of insufficient resources, particularly space, staff, and supplies. Although usually identified with disasters, these decisions can arise in other contexts where personnel or technological resources are inadequate. Indeed, one of the first modern incarnations of triage ethics in American civilian life was in the early days of hemodialysis, when so-called “God committees” made complex decisions about which patients would be able to use this new, rare technology.³

Two fundamental moral constructs undergird medical ethics: deontological and utilitarian. The former, in which most clinicians traffic in ordinary practice, is driven by principles or moral rules such as the sanctity of life, the rule of fairness, and the principle of autonomy.⁴ They apply primarily in the context of treating an individual patient. The utilitarian way of reasoning is not as familiar to clinicians. It is focused on the broader context, the common good, the health of the group. It asks to calculate “the greatest good for the greatest number” as a means of navigating ethical dilemmas.⁵ The utilitarian perspective is far more familiar to policymakers, health care administrators, and public health professionals. It tends to be anathema to clinicians. However, disasters such as the COVID-19 pandemic ask some clinicians, particularly inpatient physicians, to shift from their usual deontological perspective to a utilitarian one, because triage ethics fundamentally draw on utilitarian reasoning. This can be quite anguishing to clinicians who typically work with individual patients in settings of more adequate, if not abundant, resources. What may feel wrong in a deontological mode can be seen as ethically right in a utilitarian framework.

The Table compares and contrasts these 2 paradigms and how they manifest in the clinical trenches, in a protracted health care crisis with limited resources.

The COVID-19 crisis has produced an unprecedented and extended exposure of clinicians to triage situations in the face of limited resources such as ventilators, personnel, personal protective equipment, etc.⁶ Numerous possible approaches to deploying limited supplies are being considered. On what basis should such decisions be made? How can fairness be optimally manifest? Some possibilities include:

• first come, first served
• youngest first
• lottery
• short-term survivability
• long-term prognosis for quality of life
• value of a patient to the lives of others (eg, parents, health care workers, vaccine researchers).

One particularly interesting exploration of these questions was done in Maryland and reported in the “Maryland Framework for the Allocation of Scarce Life-sustaining Medical Resources in a Catastrophic Public Health Emergency.”⁷ This was the product of a multi-year consultation, ending in 2017, with several constituencies, including clinicians, politicians, hospital administrators, and members of the public brainstorming about approaches to allocating a hypothetical scarcity of ventilators. Interestingly, there was one broad consensus among these groups: a ventilator should not be withdrawn from a patient already using it to give to a “better” candidate who comes along later.

Some institutions have developed a method of making triage decisions that takes such decisions out of the hands of individual clinicians and instead assigns them to specialized “triage teams” made up of ethicists and clinicians experienced in critical care, to develop more distance from the emotions at the bedside. To minimize bias, such teams are often insulated from getting personal information about the patient, and receive only acute clinical information.⁸

Continue to: The pros and cons of these approaches...

The pros and cons of these approaches and the underlying ethical reasoning is beyond the scope of this overview. Policy documents from different states, regions, nations, and institutions have various approaches to making these choices. Presently, there is no coherent national or international agreement on triage ethics.⁹ It is important, however, that there be transparency in whatever approach an institution adopts for triage decisions.

Equity ethics

Though the equitable distribution of health care delivery has long been a concern, this problem has become magnified by the COVID-19 crisis. Race, sex, age, socioeconomic class, and type of illness have all been perennial sources of division between those who have better or worse access to health care and its outcomes. All of these distinctions have created differentials in rates of cases, hospitalizations, and deaths in the COVID-19 pandemic.¹⁰

The shifting of acute health care facilities to mostly COVID-19–related treatment, and postponing less critical and more “elective” care, creates a divide based on illness type. Many facilities have stopped taking admissions for other kinds of cases. This is particularly relevant to psychiatric units, many of which have had to decrease their bed capacities to make all rooms private, and limit their usual treatments offered to inpatients.¹¹ Many long-term units, such as at state hospitals, are closing to new admissions. Many day hospitals and intensive outpatient programs remain closed, not even shifting to telehealth. In areas most affected by COVID-19, some institutions have closed psychiatric wards and reallocated psychiatrists to cover some of the medical units. So the availability of the more intensive, institutionally-based levels of care is significantly reduced, particularly for psychiatric patients.¹² These patients already are a disadvantaged population in the distribution of health care resources, and the care of individuals with serious mental illness is more likely to be seen as “nonessential” in this time of suddenly scarcer institutional resources.

One of the cherished ethical values in health care is autonomy, and in a deontological triage environment, honoring patient autonomy is carefully and tenderly administered. However, in a utilitarian-driven triage environment, considerations of the common good can trump autonomy, even in subtle ways that create inequities. Clinicians have been advised to have more frank conversations with patients, particularly those with chronic illnesses, stepping up initiatives to make advanced directives during this crisis, explicitly reminding patients that there may not be enough ventilators for all who need one.¹³ Some have argued that such physician-initiated conversations can be inherently coercive, making these decisions not as autonomous as it may appear, similar to physicians suggesting medical euthanasia as an option.¹⁴ Interestingly, some jurisdictions that offer euthanasia have been suspending such services during the COVID-19 crisis.¹⁵ Some hospitals have even wrestled with the possibility that all COVID-19 admissions should be considered “do not resuscitate,” especially because cardiopulmonary resuscitation significantly elevates the risks of viral exposure for the treatment team.^16,17 A more explicit example of how current standards protecting patient autonomy may be challenged is patients who are admitted involuntarily to a psychiatric unit. These are patients whose presumptively impaired autonomy is already being overridden by the involuntary nature of the admission. If a psychiatric unit requires admissions to be COVID-19–negative, and if patients refuse COVID-19 testing, should the testing be forced upon them to protect the entire milieu?

Many ethicists are highlighting the embedded equity bias known as “ableism” inherent in triage decisions—implicitly disfavoring resources for patients with COVID-19 who are already physically or intellectually disabled, chronically ill, aged, homeless, psychosocially low functioning, etc.¹⁸ Without explicit protections for individuals who are chronically disabled, triage decisions unguided by policy safeguards may reflexively favor the more “abled.” This bias towards the more abled is often inherent in how difficult it is to access health care. It can also be manifested in bedside triage decisions made in the moment by individual clinicians. Many disability rights advocates have been sounding this alarm during the COVID-19 crisis.¹⁹

Continue to: A special circumstance of equity...

A special circumstance of equity is arising during this ongoing pandemic—the possibility of treating health care workers as a privileged class. Unlike typical disasters, where health care workers come in afterwards, and therefore are in relatively less danger, pandemics create particularly high risks of danger for such individuals, with repeated exposure to the virus. They are both responders and potential victims. Should they have higher priority for ventilators, vaccines, funding, etc?⁶ This is a more robust degree of compensatory justice than merely giving appreciation. Giving health care workers such advantages may seem intuitively appealing, but perhaps professionalism and the self-obligation of duty mitigates such claims.²⁰

A unique opportunity

The magnitude and pervasiveness of this pandemic crisis is unique in our lifetimes, as both professionals and as citizens. In the crucible of this extraordinary time, these and other medical ethics dilemmas burn hotter than ever before. Different societies and institutions may come up with different answers, based on their cultures and values. It is important, however, that the venerable ethos of medical ethics, which has evolved through the millennia, codified in oaths, codes, and scholarship, can be a compass at the bedside and in the meetings of legislatures, leaders, and policymakers. Perhaps we can emerge from this time with more clarity about how to balance the preciousness of individual rights with the needs of the common good.

Bottom Line

The coronavirus disease 2019 (COVID-19) pandemic has brought increased attention to triage ethics and equity ethics. There is no coherent national or international agreement on how to best deploy limited supplies such as ventilators and personal protective equipment. Although the equitable distribution of health care delivery has long been a concern, this problem has become magnified by COVID-19. Clinicians may be asked to view health care through the less familiar lens of the common good, as opposed to focusing strictly on an individual patient.

Related Resources

• Johns Hopkins Berman Institute of Bioethics. Coronavirus ethics and policy insights and resources. https://bioethics.jhu.edu/research-and-outreach/covid-19-bioethics-expert-insights/.
• Daugherty-Biddison L, Gwon H, Regenberg A, et al. Maryland framework for the allocation of scarce lifesustaining medical resources in a catastrophic public health emergency. www.law.umaryland.edu/media/SOL/pdfs/Programs/Health-Law/MHECN/ASR%20Framework_Final.pdf.

It is clear that the coronavirus 2019 disease (COVID-19) pandemic is one of the most extraordinary epochs of our professional and personal lives. Besides the challenges to the techniques and technologies of care for this illness, we are seeing challenges to the fundamentals of health care, both to the systems whereby it is delivered, and to the ethical principles that guide that delivery. There is unprecedented relevance of certain ethical issues in the practice of medicine, many of which have previously been discussed in classrooms and textbooks, but now are at play in daily practice, particularly at the frontlines of the war against COVID-19.¹ In this article, I highlight several ethical dilemmas that are salient to these unique times. Some of the most compelling issues can be sorted into 2 clearly overlapping domains: triage ethics and equity ethics.

Triage ethics

In the areas most greatly affected by the COVID-19 pandemic, scarcity of treatment resources, such as ventilators, is a legitimate concern. French surgeon Dominique Jean Larry was the first to establish medical sorting protocols in the context of the battles of the Napoleonic wars, for which he used the French word triage, meaning “sorting.”² He articulated 3 prognostic categories: 1) those who would die even with treatment, 2) those who would live without treatment, and 3) those who would die unless treated. Triage decisions arise in the context of insufficient resources, particularly space, staff, and supplies. Although usually identified with disasters, these decisions can arise in other contexts where personnel or technological resources are inadequate. Indeed, one of the first modern incarnations of triage ethics in American civilian life was in the early days of hemodialysis, when so-called “God committees” made complex decisions about which patients would be able to use this new, rare technology.³

Two fundamental moral constructs undergird medical ethics: deontological and utilitarian. The former, in which most clinicians traffic in ordinary practice, is driven by principles or moral rules such as the sanctity of life, the rule of fairness, and the principle of autonomy.⁴ They apply primarily in the context of treating an individual patient. The utilitarian way of reasoning is not as familiar to clinicians. It is focused on the broader context, the common good, the health of the group. It asks to calculate “the greatest good for the greatest number” as a means of navigating ethical dilemmas.⁵ The utilitarian perspective is far more familiar to policymakers, health care administrators, and public health professionals. It tends to be anathema to clinicians. However, disasters such as the COVID-19 pandemic ask some clinicians, particularly inpatient physicians, to shift from their usual deontological perspective to a utilitarian one, because triage ethics fundamentally draw on utilitarian reasoning. This can be quite anguishing to clinicians who typically work with individual patients in settings of more adequate, if not abundant, resources. What may feel wrong in a deontological mode can be seen as ethically right in a utilitarian framework.

The Table compares and contrasts these 2 paradigms and how they manifest in the clinical trenches, in a protracted health care crisis with limited resources.

The COVID-19 crisis has produced an unprecedented and extended exposure of clinicians to triage situations in the face of limited resources such as ventilators, personnel, personal protective equipment, etc.⁶ Numerous possible approaches to deploying limited supplies are being considered. On what basis should such decisions be made? How can fairness be optimally manifest? Some possibilities include:

• first come, first served
• youngest first
• lottery
• short-term survivability
• long-term prognosis for quality of life
• value of a patient to the lives of others (eg, parents, health care workers, vaccine researchers).

One particularly interesting exploration of these questions was done in Maryland and reported in the “Maryland Framework for the Allocation of Scarce Life-sustaining Medical Resources in a Catastrophic Public Health Emergency.”⁷ This was the product of a multi-year consultation, ending in 2017, with several constituencies, including clinicians, politicians, hospital administrators, and members of the public brainstorming about approaches to allocating a hypothetical scarcity of ventilators. Interestingly, there was one broad consensus among these groups: a ventilator should not be withdrawn from a patient already using it to give to a “better” candidate who comes along later.

Some institutions have developed a method of making triage decisions that takes such decisions out of the hands of individual clinicians and instead assigns them to specialized “triage teams” made up of ethicists and clinicians experienced in critical care, to develop more distance from the emotions at the bedside. To minimize bias, such teams are often insulated from getting personal information about the patient, and receive only acute clinical information.⁸

Continue to: The pros and cons of these approaches...

The pros and cons of these approaches and the underlying ethical reasoning is beyond the scope of this overview. Policy documents from different states, regions, nations, and institutions have various approaches to making these choices. Presently, there is no coherent national or international agreement on triage ethics.⁹ It is important, however, that there be transparency in whatever approach an institution adopts for triage decisions.

Equity ethics

Though the equitable distribution of health care delivery has long been a concern, this problem has become magnified by the COVID-19 crisis. Race, sex, age, socioeconomic class, and type of illness have all been perennial sources of division between those who have better or worse access to health care and its outcomes. All of these distinctions have created differentials in rates of cases, hospitalizations, and deaths in the COVID-19 pandemic.¹⁰

The shifting of acute health care facilities to mostly COVID-19–related treatment, and postponing less critical and more “elective” care, creates a divide based on illness type. Many facilities have stopped taking admissions for other kinds of cases. This is particularly relevant to psychiatric units, many of which have had to decrease their bed capacities to make all rooms private, and limit their usual treatments offered to inpatients.¹¹ Many long-term units, such as at state hospitals, are closing to new admissions. Many day hospitals and intensive outpatient programs remain closed, not even shifting to telehealth. In areas most affected by COVID-19, some institutions have closed psychiatric wards and reallocated psychiatrists to cover some of the medical units. So the availability of the more intensive, institutionally-based levels of care is significantly reduced, particularly for psychiatric patients.¹² These patients already are a disadvantaged population in the distribution of health care resources, and the care of individuals with serious mental illness is more likely to be seen as “nonessential” in this time of suddenly scarcer institutional resources.

One of the cherished ethical values in health care is autonomy, and in a deontological triage environment, honoring patient autonomy is carefully and tenderly administered. However, in a utilitarian-driven triage environment, considerations of the common good can trump autonomy, even in subtle ways that create inequities. Clinicians have been advised to have more frank conversations with patients, particularly those with chronic illnesses, stepping up initiatives to make advanced directives during this crisis, explicitly reminding patients that there may not be enough ventilators for all who need one.¹³ Some have argued that such physician-initiated conversations can be inherently coercive, making these decisions not as autonomous as it may appear, similar to physicians suggesting medical euthanasia as an option.¹⁴ Interestingly, some jurisdictions that offer euthanasia have been suspending such services during the COVID-19 crisis.¹⁵ Some hospitals have even wrestled with the possibility that all COVID-19 admissions should be considered “do not resuscitate,” especially because cardiopulmonary resuscitation significantly elevates the risks of viral exposure for the treatment team.^16,17 A more explicit example of how current standards protecting patient autonomy may be challenged is patients who are admitted involuntarily to a psychiatric unit. These are patients whose presumptively impaired autonomy is already being overridden by the involuntary nature of the admission. If a psychiatric unit requires admissions to be COVID-19–negative, and if patients refuse COVID-19 testing, should the testing be forced upon them to protect the entire milieu?

Many ethicists are highlighting the embedded equity bias known as “ableism” inherent in triage decisions—implicitly disfavoring resources for patients with COVID-19 who are already physically or intellectually disabled, chronically ill, aged, homeless, psychosocially low functioning, etc.¹⁸ Without explicit protections for individuals who are chronically disabled, triage decisions unguided by policy safeguards may reflexively favor the more “abled.” This bias towards the more abled is often inherent in how difficult it is to access health care. It can also be manifested in bedside triage decisions made in the moment by individual clinicians. Many disability rights advocates have been sounding this alarm during the COVID-19 crisis.¹⁹

Continue to: A special circumstance of equity...

A special circumstance of equity is arising during this ongoing pandemic—the possibility of treating health care workers as a privileged class. Unlike typical disasters, where health care workers come in afterwards, and therefore are in relatively less danger, pandemics create particularly high risks of danger for such individuals, with repeated exposure to the virus. They are both responders and potential victims. Should they have higher priority for ventilators, vaccines, funding, etc?⁶ This is a more robust degree of compensatory justice than merely giving appreciation. Giving health care workers such advantages may seem intuitively appealing, but perhaps professionalism and the self-obligation of duty mitigates such claims.²⁰

A unique opportunity

The magnitude and pervasiveness of this pandemic crisis is unique in our lifetimes, as both professionals and as citizens. In the crucible of this extraordinary time, these and other medical ethics dilemmas burn hotter than ever before. Different societies and institutions may come up with different answers, based on their cultures and values. It is important, however, that the venerable ethos of medical ethics, which has evolved through the millennia, codified in oaths, codes, and scholarship, can be a compass at the bedside and in the meetings of legislatures, leaders, and policymakers. Perhaps we can emerge from this time with more clarity about how to balance the preciousness of individual rights with the needs of the common good.

Bottom Line

The coronavirus disease 2019 (COVID-19) pandemic has brought increased attention to triage ethics and equity ethics. There is no coherent national or international agreement on how to best deploy limited supplies such as ventilators and personal protective equipment. Although the equitable distribution of health care delivery has long been a concern, this problem has become magnified by COVID-19. Clinicians may be asked to view health care through the less familiar lens of the common good, as opposed to focusing strictly on an individual patient.

Related Resources

• Johns Hopkins Berman Institute of Bioethics. Coronavirus ethics and policy insights and resources. https://bioethics.jhu.edu/research-and-outreach/covid-19-bioethics-expert-insights/.
• Daugherty-Biddison L, Gwon H, Regenberg A, et al. Maryland framework for the allocation of scarce lifesustaining medical resources in a catastrophic public health emergency. www.law.umaryland.edu/media/SOL/pdfs/Programs/Health-Law/MHECN/ASR%20Framework_Final.pdf.

Nausea, vomiting, and diarrhea are gastrointestinal symptoms that COVID-19 patients have had, and up to 30% have been reported to have liver symptoms. Because patients with these symptoms may require endoscopy, the American Gastroenterological Association has issued a rapid recommendation document that advises physicians and health care workers to use N95 masks, double gloves, and negative pressure rooms when performing GI procedures during the COVID-19 pandemic.

The recommendations, published in Gastroenterology (2020. doi: 10.1053/j.gastro.2020.03.072), also cover non-COVID-19 patients and situations where N95 masks should be used, offer guidelines for triaging patients for endoscopy and timing of nonurgent procedures, and evaluate the latest evidence in the incidence of GI and liver manifestations of COVID-19. The guideline panel met in March.

The document includes seven recommendations for use of personal protective equipment by physicians and nurses performing GI procedures. The recommendations and the level of evidence supporting them fall under four categories:

1. Masks, comprising four recommendations: N95 masks for upper and lower GI procedures regardless of a patient’s COVID-19 status; no surgical masks only in confirmed COVID-19 patients or suspected cases; and reused N95 masks when fresh ones aren’t available instead of using a surgical mask only (very low to moderate level of evidence depending on the recommendation).

2. Double-gloving when performing any GI procedure regardless of the patient’s COVID-19 status (moderate quality evidence).

3. When available, a negative-pressure room should be used for any COVID-19 patient or suspect rather than a regular endoscopy room (very low certainty of evidence).

4. Continue to practice standard cleaning, endoscopic disinfection, and reprocessing protocols regardless of a patient’s COVID-19 status (good practice statement).

For decontamination, the panel noted that commonly used biocidal agents, such as hydrogen peroxide, alcohols, sodium hypochlorite, or benzalkonium chloride have proved effective for decontaminating of coronavirus.

For implementing the PPE recommendations, the panel stated that personnel still need to practice don and doff standard protocols, and that N95 masks should be fitted for each individual.

Other steps include banning personal belongings in the procedure area, minimizing the number of personnel in the room, avoiding change of personnel and keeping nonprocedural personnel out during the procedure, considering using nursing teams that follow the patient through preprocedure, procedure, and recovery, and considering having endoscopy teams remain together during the day to minimize exposure.

The triage recommendations stated that “trained medical personnel” should review all procedures and categorize them as time-sensitive or not time-sensitive, based on a framework the recommendation includes. In “an open-access endoscopy system” when there isn’t enough information to determine timing for the procedure, the recommendation provides a three-step approach: a phone consult with the referring physician, a telehealth visit with the patient, or a multidisciplinary team approach or virtual disease/tumor board.

“The proposed framework of separating procedures into time-sensitive and non–time-sensitive cases may be useful in determining which procedures if delayed may negatively impact on patient-important outcomes,” wrote Shahnaz Sultan, MD, AGAF, of the University of Minnesota, Minneapolis, and colleagues. The panel noted decision-making should focus on “patient-important outcomes.”

For nonurgent procedures, the panel arrived at a consensus that 8 weeks was an appropriate window for reassessment of deferred procedures, depending on the availability of resources and if the time sensitivity of the procedure changes.

The panel also attempted to determine the likelihood of GI and liver manifestations of COVID-19 by evaluating published cohort studies. They found that 2%-13.8% of patients had diarrhea, 1%-10.1% had nausea or vomiting, and one study reported 2% had abdominal pain (Am J Gastroenterol. 2020 May;115[5]766-73). What’s more, some studies have shown stool samples positive for SARS-CoV-2 RNA even after respiratory samples were negative.

The evidence on liver manifestations isn’t as robust, but one study reported that 20%-30% of patients had liver injury upon diagnosis of COVID-19 (Gastroenterology. 2020;158:1518-9), and that severe hepatitis has been reported but liver failure seems rare (Lancet. 2020 Feb 15;395[10223]:507-13). “The pattern of liver injury appears to be predominantly hepatocellular, and the etiology remains uncertain but may represent a secondary effect of the systemic inflammatory response observed with COVID-19 disease, although direct viral infection and drug-induced liver injury cannot be excluded,” Dr. Sultan and colleagues noted.

There were no relevant author conflicts of interest. The American Gastroenterological Association (AGA) Institute funded the study.

SOURCE: Sultan S et al. Gastroenterology. 2020. doi: 10.1053/j.gastro.2020.03.072.

Nausea, vomiting, and diarrhea are gastrointestinal symptoms that COVID-19 patients have had, and up to 30% have been reported to have liver symptoms. Because patients with these symptoms may require endoscopy, the American Gastroenterological Association has issued a rapid recommendation document that advises physicians and health care workers to use N95 masks, double gloves, and negative pressure rooms when performing GI procedures during the COVID-19 pandemic.

The recommendations, published in Gastroenterology (2020. doi: 10.1053/j.gastro.2020.03.072), also cover non-COVID-19 patients and situations where N95 masks should be used, offer guidelines for triaging patients for endoscopy and timing of nonurgent procedures, and evaluate the latest evidence in the incidence of GI and liver manifestations of COVID-19. The guideline panel met in March.

The document includes seven recommendations for use of personal protective equipment by physicians and nurses performing GI procedures. The recommendations and the level of evidence supporting them fall under four categories:

1. Masks, comprising four recommendations: N95 masks for upper and lower GI procedures regardless of a patient’s COVID-19 status; no surgical masks only in confirmed COVID-19 patients or suspected cases; and reused N95 masks when fresh ones aren’t available instead of using a surgical mask only (very low to moderate level of evidence depending on the recommendation).

2. Double-gloving when performing any GI procedure regardless of the patient’s COVID-19 status (moderate quality evidence).

3. When available, a negative-pressure room should be used for any COVID-19 patient or suspect rather than a regular endoscopy room (very low certainty of evidence).

4. Continue to practice standard cleaning, endoscopic disinfection, and reprocessing protocols regardless of a patient’s COVID-19 status (good practice statement).

For decontamination, the panel noted that commonly used biocidal agents, such as hydrogen peroxide, alcohols, sodium hypochlorite, or benzalkonium chloride have proved effective for decontaminating of coronavirus.

For implementing the PPE recommendations, the panel stated that personnel still need to practice don and doff standard protocols, and that N95 masks should be fitted for each individual.

Other steps include banning personal belongings in the procedure area, minimizing the number of personnel in the room, avoiding change of personnel and keeping nonprocedural personnel out during the procedure, considering using nursing teams that follow the patient through preprocedure, procedure, and recovery, and considering having endoscopy teams remain together during the day to minimize exposure.

The triage recommendations stated that “trained medical personnel” should review all procedures and categorize them as time-sensitive or not time-sensitive, based on a framework the recommendation includes. In “an open-access endoscopy system” when there isn’t enough information to determine timing for the procedure, the recommendation provides a three-step approach: a phone consult with the referring physician, a telehealth visit with the patient, or a multidisciplinary team approach or virtual disease/tumor board.

“The proposed framework of separating procedures into time-sensitive and non–time-sensitive cases may be useful in determining which procedures if delayed may negatively impact on patient-important outcomes,” wrote Shahnaz Sultan, MD, AGAF, of the University of Minnesota, Minneapolis, and colleagues. The panel noted decision-making should focus on “patient-important outcomes.”

For nonurgent procedures, the panel arrived at a consensus that 8 weeks was an appropriate window for reassessment of deferred procedures, depending on the availability of resources and if the time sensitivity of the procedure changes.

The panel also attempted to determine the likelihood of GI and liver manifestations of COVID-19 by evaluating published cohort studies. They found that 2%-13.8% of patients had diarrhea, 1%-10.1% had nausea or vomiting, and one study reported 2% had abdominal pain (Am J Gastroenterol. 2020 May;115[5]766-73). What’s more, some studies have shown stool samples positive for SARS-CoV-2 RNA even after respiratory samples were negative.

The evidence on liver manifestations isn’t as robust, but one study reported that 20%-30% of patients had liver injury upon diagnosis of COVID-19 (Gastroenterology. 2020;158:1518-9), and that severe hepatitis has been reported but liver failure seems rare (Lancet. 2020 Feb 15;395[10223]:507-13). “The pattern of liver injury appears to be predominantly hepatocellular, and the etiology remains uncertain but may represent a secondary effect of the systemic inflammatory response observed with COVID-19 disease, although direct viral infection and drug-induced liver injury cannot be excluded,” Dr. Sultan and colleagues noted.

There were no relevant author conflicts of interest. The American Gastroenterological Association (AGA) Institute funded the study.

SOURCE: Sultan S et al. Gastroenterology. 2020. doi: 10.1053/j.gastro.2020.03.072.

Nausea, vomiting, and diarrhea are gastrointestinal symptoms that COVID-19 patients have had, and up to 30% have been reported to have liver symptoms. Because patients with these symptoms may require endoscopy, the American Gastroenterological Association has issued a rapid recommendation document that advises physicians and health care workers to use N95 masks, double gloves, and negative pressure rooms when performing GI procedures during the COVID-19 pandemic.

The recommendations, published in Gastroenterology (2020. doi: 10.1053/j.gastro.2020.03.072), also cover non-COVID-19 patients and situations where N95 masks should be used, offer guidelines for triaging patients for endoscopy and timing of nonurgent procedures, and evaluate the latest evidence in the incidence of GI and liver manifestations of COVID-19. The guideline panel met in March.

The document includes seven recommendations for use of personal protective equipment by physicians and nurses performing GI procedures. The recommendations and the level of evidence supporting them fall under four categories:

1. Masks, comprising four recommendations: N95 masks for upper and lower GI procedures regardless of a patient’s COVID-19 status; no surgical masks only in confirmed COVID-19 patients or suspected cases; and reused N95 masks when fresh ones aren’t available instead of using a surgical mask only (very low to moderate level of evidence depending on the recommendation).

2. Double-gloving when performing any GI procedure regardless of the patient’s COVID-19 status (moderate quality evidence).

3. When available, a negative-pressure room should be used for any COVID-19 patient or suspect rather than a regular endoscopy room (very low certainty of evidence).

4. Continue to practice standard cleaning, endoscopic disinfection, and reprocessing protocols regardless of a patient’s COVID-19 status (good practice statement).

For decontamination, the panel noted that commonly used biocidal agents, such as hydrogen peroxide, alcohols, sodium hypochlorite, or benzalkonium chloride have proved effective for decontaminating of coronavirus.

For implementing the PPE recommendations, the panel stated that personnel still need to practice don and doff standard protocols, and that N95 masks should be fitted for each individual.

Other steps include banning personal belongings in the procedure area, minimizing the number of personnel in the room, avoiding change of personnel and keeping nonprocedural personnel out during the procedure, considering using nursing teams that follow the patient through preprocedure, procedure, and recovery, and considering having endoscopy teams remain together during the day to minimize exposure.

The triage recommendations stated that “trained medical personnel” should review all procedures and categorize them as time-sensitive or not time-sensitive, based on a framework the recommendation includes. In “an open-access endoscopy system” when there isn’t enough information to determine timing for the procedure, the recommendation provides a three-step approach: a phone consult with the referring physician, a telehealth visit with the patient, or a multidisciplinary team approach or virtual disease/tumor board.

“The proposed framework of separating procedures into time-sensitive and non–time-sensitive cases may be useful in determining which procedures if delayed may negatively impact on patient-important outcomes,” wrote Shahnaz Sultan, MD, AGAF, of the University of Minnesota, Minneapolis, and colleagues. The panel noted decision-making should focus on “patient-important outcomes.”

For nonurgent procedures, the panel arrived at a consensus that 8 weeks was an appropriate window for reassessment of deferred procedures, depending on the availability of resources and if the time sensitivity of the procedure changes.

The panel also attempted to determine the likelihood of GI and liver manifestations of COVID-19 by evaluating published cohort studies. They found that 2%-13.8% of patients had diarrhea, 1%-10.1% had nausea or vomiting, and one study reported 2% had abdominal pain (Am J Gastroenterol. 2020 May;115[5]766-73). What’s more, some studies have shown stool samples positive for SARS-CoV-2 RNA even after respiratory samples were negative.

The evidence on liver manifestations isn’t as robust, but one study reported that 20%-30% of patients had liver injury upon diagnosis of COVID-19 (Gastroenterology. 2020;158:1518-9), and that severe hepatitis has been reported but liver failure seems rare (Lancet. 2020 Feb 15;395[10223]:507-13). “The pattern of liver injury appears to be predominantly hepatocellular, and the etiology remains uncertain but may represent a secondary effect of the systemic inflammatory response observed with COVID-19 disease, although direct viral infection and drug-induced liver injury cannot be excluded,” Dr. Sultan and colleagues noted.

There were no relevant author conflicts of interest. The American Gastroenterological Association (AGA) Institute funded the study.

SOURCE: Sultan S et al. Gastroenterology. 2020. doi: 10.1053/j.gastro.2020.03.072.

Nisha Mehta, MD, said her phone has been ringing with calls from tearful and shaken physicians who are distressed and unsettled about their work and home situation and don’t know what to do.

What’s more, many frontline physicians are living apart from family to protect them from infection. “So many physicians have called me crying. ... They can’t even come home and get a hug,” Dr. Mehta said. “What I’m hearing from a lot of people who are in New York and New Jersey is not just that they go to work all day and it’s this exhausting process throughout the entire day, not only physically but also emotionally.”

Physician burnout has held a steady spotlight since long before the COVID-19 crisis began, Dr. Mehta said. “The reason for that is multifold, but in part, it’s hard for physicians to find an appropriate way to be able to process a lot of the emotions related to their work,” she said. “A lot of that brews below the surface, but COVID-19 has really brought many of these issues above that surface.”

Frustrated that governments weren’t doing enough to support health care workers during the pandemic, Dr. Mehta, a radiologist in Charlotte, N.C., decided there needed to be change. On April 4, Dr. Mehta and two physician colleagues submitted to Congress the COVID-19 Pandemic Physician Protection Act, which ensures, among other provisions, mental health coverage for health care workers. An accompanying petition on change.org had received nearly 300,000 signatures as of May 29.
 

Don’t suffer in silence

A career in medicine comes with immense stress in the best of times, she notes, and managing a pandemic in an already strained system has taken those challenges to newer heights. “We need better support structures at baseline for physician mental health,” said Dr. Mehta.

“That’s something we’ve always been lacking because it’s been against the culture of medicine for so long to say, ‘I’m having a hard time.’ ”

If you’re hurting, the first thing to recognize is that you are not alone in facing these challenges. This is true with respect not only to medical care but also to all of the family, financial, and business concerns physicians are currently facing. “Having all of those things hanging over your head is a lot. We’ve got to find ways to help each other out,” Dr. Mehta said.
 

Where to find support

Fortunately, the medical community has created several pathways to help its own. Types of resources for health care workers on the COVID-19 frontlines run the gamut from crisis hotlines to smartphone apps to virtual counseling, often for free or at discounted rates.

The following list represents a cross-section of opportunities for caregivers to receive care for themselves.

Crisis hotlines

• Physician Support Line. This free and confidential hotline was launched on March 30 by Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group. The PSL is run by more than 600 volunteer psychiatrists who take calls from U.S. physicians 7 days a week from 8:00 a.m. to 1:00 a.m., with no appointment necessary. The toll-free number is 888-409-0141.
• For the Frontlines. This 24/7 help line provides free crisis counseling for frontline workers. They can text FRONTLINE to 741741 in the United States (support is also available for residents of Canada, Ireland, and the United Kingdom).

Resources from professional groups

• Action Collaborative on Clinician Well-Being and Resilience. Created by the National Academy of Medicine in 2017, the Action Collaborative comprises more than 60 organizations committed to reversing trends in clinician burnout. In response to the pandemic, the group has compiled a list of strategies and resources to support the health and well-being of clinicians who are providing healthcare during the COVID-19 outbreak.
• American Medical Association. The AMA has created a resource center dedicated to providing care for caregivers during the COVID-19 pandemic. The website includes specific guidance for managing mental health during the pandemic.
• American College of Physicians. The professional society of internal medicine physicians has created a comprehensive guide for physicians specific to COVID-19, with a section dedicated to clinician well-being that includes information about hotlines, counseling services, grief support, and more.
• American Hospital Association. The AHA’s website now includes regularly updated resources for healthcare clinicians and staff, as well as a special section dedicated to protecting and enabling healthcare workers in the midst of the pandemic.

Virtual psychological counseling

Not unlike the way telemedicine has allowed some physicians to keep seeing their patients, many modalities enable participation in therapy through video, chat, phone call, or any combination thereof. Look for a service that is convenient, flexible, and HIPAA compliant.

Traditional in-office mental health therapy has quickly moved to telemedicine. Many if not most insurers that cover counseling visits are paying for telepsychiatry or telecounseling. If you don’t know of an appropriate therapist, check the American Psychiatric Association or its state chapters; the American Psychological Association; or look for a licensed mental health counselor.

Because financial constraints are a potential barrier to therapy, Project Parachute, in cooperation with Eleos Health, has organized a cadre of therapists willing to provide pro bono online therapy for health care workers. The amount of free therapy provided to qualified frontline workers is up to the individual therapists. Discuss these parameters with your therapists up front.

Similar services are offered from companies such as Talkspace and BetterHelp on a subscription basis. These services are typically less expensive than in-person sessions. Ask about discounts for healthcare workers. Talkspace, for example, announced in March, “Effective immediately, healthcare workers across the country can get access to a free month of our...online therapy that includes unlimited text, video, and audio messaging with a licensed therapist.”
 

Online support groups and social media

For more on-demand peer support, look for groups such as the COR Sharing Circle for Healthcare Workers on Facebook. The site’s search engine can point users to plenty of other groups, many of which are closed (meaning posts are visible to members only).

Dr. Mehta hosts her own Facebook group called Physician Community. “I would like to think (and genuinely feel) that we’ve been doing a great job of supporting each other there with daily threads on challenges, treatments, pick-me-ups, vent posts, advocacy, and more,” she said.

For anyone in need, PeerRxMed is a free, peer-to-peer program for physicians and other health care workers that is designed to provide support, connection, encouragement, resources, and skill-building to optimize well-being.

For those craving spiritual comfort during this crisis, a number of churches have begun offering that experience virtually, too. First Unitarian Church of Worcester, Massachusetts, for example, offers weekly services via YouTube. Similar online programming is being offered from all sorts of organizations across denominations.
 

Apps

For DIY or on-the-spot coping support, apps can help physicians get through the day. Apps and websites that offer guided meditations and other relaxation tools include Headspace, Calm, and Insight Timer. Before downloading, look for special discounts and promotions for healthcare workers.

Additionally, COVID Coach is a free, secure app designed by the U.S. Department of Veterans Affairs that includes tools to help you cope with stress and stay well, safe, healthy, and connected. It also offers advice on navigating parenting, care giving, and working from home while social distancing, quarantined, or sheltering in place.

For practicing daily gratitude, Delightful Journal is a free app that offers journaling prompts, themes, reminders, and unlimited private space to record one’s thoughts.
 

Adopt a ritual

Although self-care for physicians is more crucial now than ever, it can look different for every individual. Along the same lines as keeping a journal, wellness experts often recommend beginning a “gratitude practice” to help provide solace and perspective.

Tweak and personalize these activities to suit your own needs, but be sure to use them even when you’re feeling well, said Mohana Karlekar, MD, medical director of palliative care and assistant professor at Vanderbilt University Medical Center, Nashville, Tenn.

One exercise she recommends is known as Three Good Things. “Every day, at the end of the day, think about three good things that have happened,” she explained. “You can always find the joys. And the joys don’t have to be enormous. There is joy – there is hope – in everything,” Dr. Karlekar said.

A version of this article originally appeared on Medscape.com.

Nisha Mehta, MD, said her phone has been ringing with calls from tearful and shaken physicians who are distressed and unsettled about their work and home situation and don’t know what to do.

What’s more, many frontline physicians are living apart from family to protect them from infection. “So many physicians have called me crying. ... They can’t even come home and get a hug,” Dr. Mehta said. “What I’m hearing from a lot of people who are in New York and New Jersey is not just that they go to work all day and it’s this exhausting process throughout the entire day, not only physically but also emotionally.”

Physician burnout has held a steady spotlight since long before the COVID-19 crisis began, Dr. Mehta said. “The reason for that is multifold, but in part, it’s hard for physicians to find an appropriate way to be able to process a lot of the emotions related to their work,” she said. “A lot of that brews below the surface, but COVID-19 has really brought many of these issues above that surface.”

Frustrated that governments weren’t doing enough to support health care workers during the pandemic, Dr. Mehta, a radiologist in Charlotte, N.C., decided there needed to be change. On April 4, Dr. Mehta and two physician colleagues submitted to Congress the COVID-19 Pandemic Physician Protection Act, which ensures, among other provisions, mental health coverage for health care workers. An accompanying petition on change.org had received nearly 300,000 signatures as of May 29.
 

Don’t suffer in silence

A career in medicine comes with immense stress in the best of times, she notes, and managing a pandemic in an already strained system has taken those challenges to newer heights. “We need better support structures at baseline for physician mental health,” said Dr. Mehta.

“That’s something we’ve always been lacking because it’s been against the culture of medicine for so long to say, ‘I’m having a hard time.’ ”

If you’re hurting, the first thing to recognize is that you are not alone in facing these challenges. This is true with respect not only to medical care but also to all of the family, financial, and business concerns physicians are currently facing. “Having all of those things hanging over your head is a lot. We’ve got to find ways to help each other out,” Dr. Mehta said.
 

Where to find support

Fortunately, the medical community has created several pathways to help its own. Types of resources for health care workers on the COVID-19 frontlines run the gamut from crisis hotlines to smartphone apps to virtual counseling, often for free or at discounted rates.

The following list represents a cross-section of opportunities for caregivers to receive care for themselves.

Crisis hotlines

• Physician Support Line. This free and confidential hotline was launched on March 30 by Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group. The PSL is run by more than 600 volunteer psychiatrists who take calls from U.S. physicians 7 days a week from 8:00 a.m. to 1:00 a.m., with no appointment necessary. The toll-free number is 888-409-0141.
• For the Frontlines. This 24/7 help line provides free crisis counseling for frontline workers. They can text FRONTLINE to 741741 in the United States (support is also available for residents of Canada, Ireland, and the United Kingdom).

Resources from professional groups

• Action Collaborative on Clinician Well-Being and Resilience. Created by the National Academy of Medicine in 2017, the Action Collaborative comprises more than 60 organizations committed to reversing trends in clinician burnout. In response to the pandemic, the group has compiled a list of strategies and resources to support the health and well-being of clinicians who are providing healthcare during the COVID-19 outbreak.
• American Medical Association. The AMA has created a resource center dedicated to providing care for caregivers during the COVID-19 pandemic. The website includes specific guidance for managing mental health during the pandemic.
• American College of Physicians. The professional society of internal medicine physicians has created a comprehensive guide for physicians specific to COVID-19, with a section dedicated to clinician well-being that includes information about hotlines, counseling services, grief support, and more.
• American Hospital Association. The AHA’s website now includes regularly updated resources for healthcare clinicians and staff, as well as a special section dedicated to protecting and enabling healthcare workers in the midst of the pandemic.

Virtual psychological counseling

Not unlike the way telemedicine has allowed some physicians to keep seeing their patients, many modalities enable participation in therapy through video, chat, phone call, or any combination thereof. Look for a service that is convenient, flexible, and HIPAA compliant.

Traditional in-office mental health therapy has quickly moved to telemedicine. Many if not most insurers that cover counseling visits are paying for telepsychiatry or telecounseling. If you don’t know of an appropriate therapist, check the American Psychiatric Association or its state chapters; the American Psychological Association; or look for a licensed mental health counselor.

Because financial constraints are a potential barrier to therapy, Project Parachute, in cooperation with Eleos Health, has organized a cadre of therapists willing to provide pro bono online therapy for health care workers. The amount of free therapy provided to qualified frontline workers is up to the individual therapists. Discuss these parameters with your therapists up front.

Similar services are offered from companies such as Talkspace and BetterHelp on a subscription basis. These services are typically less expensive than in-person sessions. Ask about discounts for healthcare workers. Talkspace, for example, announced in March, “Effective immediately, healthcare workers across the country can get access to a free month of our...online therapy that includes unlimited text, video, and audio messaging with a licensed therapist.”
 

Online support groups and social media

For more on-demand peer support, look for groups such as the COR Sharing Circle for Healthcare Workers on Facebook. The site’s search engine can point users to plenty of other groups, many of which are closed (meaning posts are visible to members only).

Dr. Mehta hosts her own Facebook group called Physician Community. “I would like to think (and genuinely feel) that we’ve been doing a great job of supporting each other there with daily threads on challenges, treatments, pick-me-ups, vent posts, advocacy, and more,” she said.

For anyone in need, PeerRxMed is a free, peer-to-peer program for physicians and other health care workers that is designed to provide support, connection, encouragement, resources, and skill-building to optimize well-being.

For those craving spiritual comfort during this crisis, a number of churches have begun offering that experience virtually, too. First Unitarian Church of Worcester, Massachusetts, for example, offers weekly services via YouTube. Similar online programming is being offered from all sorts of organizations across denominations.
 

Apps

For DIY or on-the-spot coping support, apps can help physicians get through the day. Apps and websites that offer guided meditations and other relaxation tools include Headspace, Calm, and Insight Timer. Before downloading, look for special discounts and promotions for healthcare workers.

Additionally, COVID Coach is a free, secure app designed by the U.S. Department of Veterans Affairs that includes tools to help you cope with stress and stay well, safe, healthy, and connected. It also offers advice on navigating parenting, care giving, and working from home while social distancing, quarantined, or sheltering in place.

For practicing daily gratitude, Delightful Journal is a free app that offers journaling prompts, themes, reminders, and unlimited private space to record one’s thoughts.
 

Adopt a ritual

Although self-care for physicians is more crucial now than ever, it can look different for every individual. Along the same lines as keeping a journal, wellness experts often recommend beginning a “gratitude practice” to help provide solace and perspective.

Tweak and personalize these activities to suit your own needs, but be sure to use them even when you’re feeling well, said Mohana Karlekar, MD, medical director of palliative care and assistant professor at Vanderbilt University Medical Center, Nashville, Tenn.

One exercise she recommends is known as Three Good Things. “Every day, at the end of the day, think about three good things that have happened,” she explained. “You can always find the joys. And the joys don’t have to be enormous. There is joy – there is hope – in everything,” Dr. Karlekar said.

A version of this article originally appeared on Medscape.com.

Nisha Mehta, MD, said her phone has been ringing with calls from tearful and shaken physicians who are distressed and unsettled about their work and home situation and don’t know what to do.

What’s more, many frontline physicians are living apart from family to protect them from infection. “So many physicians have called me crying. ... They can’t even come home and get a hug,” Dr. Mehta said. “What I’m hearing from a lot of people who are in New York and New Jersey is not just that they go to work all day and it’s this exhausting process throughout the entire day, not only physically but also emotionally.”

Physician burnout has held a steady spotlight since long before the COVID-19 crisis began, Dr. Mehta said. “The reason for that is multifold, but in part, it’s hard for physicians to find an appropriate way to be able to process a lot of the emotions related to their work,” she said. “A lot of that brews below the surface, but COVID-19 has really brought many of these issues above that surface.”

Frustrated that governments weren’t doing enough to support health care workers during the pandemic, Dr. Mehta, a radiologist in Charlotte, N.C., decided there needed to be change. On April 4, Dr. Mehta and two physician colleagues submitted to Congress the COVID-19 Pandemic Physician Protection Act, which ensures, among other provisions, mental health coverage for health care workers. An accompanying petition on change.org had received nearly 300,000 signatures as of May 29.
 

Don’t suffer in silence

A career in medicine comes with immense stress in the best of times, she notes, and managing a pandemic in an already strained system has taken those challenges to newer heights. “We need better support structures at baseline for physician mental health,” said Dr. Mehta.

“That’s something we’ve always been lacking because it’s been against the culture of medicine for so long to say, ‘I’m having a hard time.’ ”

If you’re hurting, the first thing to recognize is that you are not alone in facing these challenges. This is true with respect not only to medical care but also to all of the family, financial, and business concerns physicians are currently facing. “Having all of those things hanging over your head is a lot. We’ve got to find ways to help each other out,” Dr. Mehta said.
 

Where to find support

Fortunately, the medical community has created several pathways to help its own. Types of resources for health care workers on the COVID-19 frontlines run the gamut from crisis hotlines to smartphone apps to virtual counseling, often for free or at discounted rates.

The following list represents a cross-section of opportunities for caregivers to receive care for themselves.

Crisis hotlines

• Physician Support Line. This free and confidential hotline was launched on March 30 by Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group. The PSL is run by more than 600 volunteer psychiatrists who take calls from U.S. physicians 7 days a week from 8:00 a.m. to 1:00 a.m., with no appointment necessary. The toll-free number is 888-409-0141.
• For the Frontlines. This 24/7 help line provides free crisis counseling for frontline workers. They can text FRONTLINE to 741741 in the United States (support is also available for residents of Canada, Ireland, and the United Kingdom).

Resources from professional groups

• Action Collaborative on Clinician Well-Being and Resilience. Created by the National Academy of Medicine in 2017, the Action Collaborative comprises more than 60 organizations committed to reversing trends in clinician burnout. In response to the pandemic, the group has compiled a list of strategies and resources to support the health and well-being of clinicians who are providing healthcare during the COVID-19 outbreak.
• American Medical Association. The AMA has created a resource center dedicated to providing care for caregivers during the COVID-19 pandemic. The website includes specific guidance for managing mental health during the pandemic.
• American College of Physicians. The professional society of internal medicine physicians has created a comprehensive guide for physicians specific to COVID-19, with a section dedicated to clinician well-being that includes information about hotlines, counseling services, grief support, and more.
• American Hospital Association. The AHA’s website now includes regularly updated resources for healthcare clinicians and staff, as well as a special section dedicated to protecting and enabling healthcare workers in the midst of the pandemic.

Virtual psychological counseling

Not unlike the way telemedicine has allowed some physicians to keep seeing their patients, many modalities enable participation in therapy through video, chat, phone call, or any combination thereof. Look for a service that is convenient, flexible, and HIPAA compliant.

Traditional in-office mental health therapy has quickly moved to telemedicine. Many if not most insurers that cover counseling visits are paying for telepsychiatry or telecounseling. If you don’t know of an appropriate therapist, check the American Psychiatric Association or its state chapters; the American Psychological Association; or look for a licensed mental health counselor.

Because financial constraints are a potential barrier to therapy, Project Parachute, in cooperation with Eleos Health, has organized a cadre of therapists willing to provide pro bono online therapy for health care workers. The amount of free therapy provided to qualified frontline workers is up to the individual therapists. Discuss these parameters with your therapists up front.

Similar services are offered from companies such as Talkspace and BetterHelp on a subscription basis. These services are typically less expensive than in-person sessions. Ask about discounts for healthcare workers. Talkspace, for example, announced in March, “Effective immediately, healthcare workers across the country can get access to a free month of our...online therapy that includes unlimited text, video, and audio messaging with a licensed therapist.”
 

Online support groups and social media

For more on-demand peer support, look for groups such as the COR Sharing Circle for Healthcare Workers on Facebook. The site’s search engine can point users to plenty of other groups, many of which are closed (meaning posts are visible to members only).

Dr. Mehta hosts her own Facebook group called Physician Community. “I would like to think (and genuinely feel) that we’ve been doing a great job of supporting each other there with daily threads on challenges, treatments, pick-me-ups, vent posts, advocacy, and more,” she said.

For anyone in need, PeerRxMed is a free, peer-to-peer program for physicians and other health care workers that is designed to provide support, connection, encouragement, resources, and skill-building to optimize well-being.

For those craving spiritual comfort during this crisis, a number of churches have begun offering that experience virtually, too. First Unitarian Church of Worcester, Massachusetts, for example, offers weekly services via YouTube. Similar online programming is being offered from all sorts of organizations across denominations.
 

Apps

For DIY or on-the-spot coping support, apps can help physicians get through the day. Apps and websites that offer guided meditations and other relaxation tools include Headspace, Calm, and Insight Timer. Before downloading, look for special discounts and promotions for healthcare workers.

Additionally, COVID Coach is a free, secure app designed by the U.S. Department of Veterans Affairs that includes tools to help you cope with stress and stay well, safe, healthy, and connected. It also offers advice on navigating parenting, care giving, and working from home while social distancing, quarantined, or sheltering in place.

For practicing daily gratitude, Delightful Journal is a free app that offers journaling prompts, themes, reminders, and unlimited private space to record one’s thoughts.
 

Adopt a ritual

Although self-care for physicians is more crucial now than ever, it can look different for every individual. Along the same lines as keeping a journal, wellness experts often recommend beginning a “gratitude practice” to help provide solace and perspective.

Tweak and personalize these activities to suit your own needs, but be sure to use them even when you’re feeling well, said Mohana Karlekar, MD, medical director of palliative care and assistant professor at Vanderbilt University Medical Center, Nashville, Tenn.

One exercise she recommends is known as Three Good Things. “Every day, at the end of the day, think about three good things that have happened,” she explained. “You can always find the joys. And the joys don’t have to be enormous. There is joy – there is hope – in everything,” Dr. Karlekar said.

A version of this article originally appeared on Medscape.com.

Even before Atlanta had an official shelter-in-place order, patients at the private plastic surgery practice of Nicholas Jones, MD, began canceling and rescheduled planned procedures.

After a few weeks, Dr. Jones, aged 40 years, stopped seeing patients entirely, but as a self-employed independent contractor, that means he’d lost most of his income. Dr. Jones still makes some money via a wound care job at a local nursing home, but he’s concerned that job may also be eliminated.

“I’m not hurting yet,” he said. “But I’m preparing for the worst possible scenario.”

In preparation, he and his fiancé have cut back on extraneous expenses like Uber Eats, magazine subscriptions, and streaming music services. Even though he has a 6-month emergency fund, Jones has reached out to utility companies, mortgage lenders, and student loan servicers to find out about any programs they offer to people who’ve suffered financially from the coronavirus crisis.

He’s also considered traveling to one of the COVID-19 epicenters – he has family in New Orleans and Chicago – to work in a hospital there. Jones has trauma experience and is double-boarded in general and plastic surgery.

“I could provide relief to those in need and also float through this troubled time with some financial relief,” he said.

Whereas much of the world’s attention has been on physicians who are on the front line and working around the clock in hospitals to help COVID-19 patients, thousands of other physicians are experiencing the opposite phenomenon – a slowdown or even stoppage of work (and income) altogether.

Many practices are temporarily closing to meet social distancing requirements, and some may end up closed for months, leaving doctors without a source of income. Even among those practices that remain open, the number of patients has declined as people avoid going to the office unless they absolutely have to.

At the same time, doctors in two-income households may have a spouse experiencing a job loss or income decline. Nearly 10 million Americans applied for unemployment benefits in the last 2 weeks of March, the largest number on record.

Still, while there’s uncertainty around how long the coronavirus crisis will last, experts agree that at some point America will return to a “new normal” and business operations will begin to reopen. For physicians experiencing a reduction in income who, like Jones, have an emergency fund with a few months’ worth of expenses, now’s the time to tap into it. (Or if you still have income, now’s the time to focus on growing that emergency fund to give yourself an even bigger safety net.)

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here’s how to stay afloat in the near term:
 

Cut back on expenses

Some household spending has naturally tapered off for many families because social distancing restrictions reduce spending on eating out, travel, and other leisure activities. But this is also an opportunity to look for other ways to reduce spending. Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need.

Some gyms are not allowing membership termination right now, but it pays to ask. If a service you’re not using won’t facilitate the cancellation, call your credit card company to dispute and stop the charges, and report them to the Better Business Bureau.

You should also stop contributing to nonemergency savings accounts such as your retirement fund or your children’s college funds.

“A lot of people are hesitant to stop their automatic savings if they’ve been maxing out their 401(k) contribution or 529 accounts,” says Andrew Musbach, a certified financial planner and cofounder of MD Wealth Management in Chelsea, Mich. “But if you’re thinking long term, the reality is that missing a couple of months won’t make or break a plan. Cutting back on the amount you’re saving in the short term will increase your cash flow and is a good way to make ends meet.”
 

Take advantage of regulatory changes

Although many physicians won’t qualify for direct payments via the Coronavirus Aid Relief and Economic Security (CARES) Act (the $1,200 payments to individuals start phasing out once income hits $75,000 and disappear entirely for those making more than $99,000), there are other provisions in the stimulus bill that may help physicians. The bill, for example, boosts state unemployment payments by $600 per week for the next 4 months, meaning qualified workers could receive an average of nearly $1,000 per week, depending on their state, and there are new provisions providing unemployment payments to self-employed and contract workers.

The CARES Act also includes a break for federal student loan holders. Under that rule, you can skip your payments through September without incurring additional interest. Physicians in the loan forgiveness program will still get credit for payments skipped during this program.

Separately, the IRS has extended the tax deadline from April 15 to July 15, which means not only do you not have to file your taxes until then, you also don’t have to pay any taxes you owe until mid-July. The deadline for first quarter estimated tax payments has also moved to July 15. (If you’re expecting a refund, however, you should file ASAP, since the IRS will typically issue those within a few weeks of receiving your returns.)
 

Tap your home equity – if you’re planning to stay put

If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Interest rates have fallen recently amid economic turbulence, so if you haven’t refinanced recently you may be able to shave your monthly payment. If you need cash, a cash-out refinance, home equity line of credit, or a reverse mortgage (available if you’re over age 62) are among the lowest-cost ways to borrow.

“With interest rates so low, there can be a lot of benefit to refinancing and leveraging your house, especially if you’re planning to stay there,” says Jamie Hopkins, a director at the Carson Group. “The challenge is if you’re planning to move in the next few years. There’s a real risk that the housing market could go down in the next couple of years, and if you’re planning to sell, there’s a risk that you might not get back what you borrowed.”
 

Communicate early with your bank or landlord

If you don’t have the income to refinance, and you think you’re going to run into trouble making your housing payment, you should let your bank or landlord know as soon as possible. The CARES Act allows homeowners with federally backed mortgages to obtain a 180-day postponement of mortgage payments because of COVID-19 financial hardship, with the potential to extend for another 180 days. It also bans eviction by landlords with federal mortgages for 120 days.

Even if you don’t have a federally backed mortgage, you should still get in touch with your lender. Many mortgage servicers have their own forbearance programs for borrowers who can prove a temporary financial hardship. (Some banks are also waiving fees on early withdrawals on CDs and giving cardholders a reprieve on credit card payments.) Commercial landlords are also working with struggling tenants, so you may also be able to get some relief on your office lease as well.

“All of the lenders are setting up helplines for people affected,” says Amy Guerich, a partner with Stepp & Rothwell, a Kansas City–based financial planning firm. “The best thing you can do is contact them right away if you think that you’re going to have a problem vs. just letting the bills go.”
 

Consider retirement account withdrawals

Standard personal finance advice holds that you should exhaust all other options before pulling money out of your retirement account because of the high penalties for early withdrawals and because money removed from retirement accounts is no longer compounding over time.

Still, the CARES act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. You’ll owe ordinary income taxes on the withdrawal, but you have 3 years to pay them or to return the money to your retirement account.

“That’s a great relief provision, especially for higher-income physicians who might have a higher 401(k) balance,” said Jamie Hopkins.
 

Be smart about credit cards

Although using credit cards that you can’t pay off every month is typically an expensive way to access money, getting a new card with a low or zero percent introductory rate is a short-term strategy to consider when you’ve exhausted other options. If you have good credit, you may be able to qualify for a credit card with a 0% introductory interest rate on new transactions. Pay close attention to the fine print, including the cap on the balance you can carry without interest and whether you’ll be required to make minimum payments.

The average 0% credit card offer is for 11 months, but there are some cards that can extend the offer for up to a year-and-a-half. If you choose to use this strategy, you’ll need a plan to pay off the entire balance before the introductory period ends. If there’s a balance remaining once the rate resets, you may end up owing deferred interest on it.

The financial ramifications of the coronavirus can feel overwhelming, but it’s important not to panic. While it remains unclear how long the current crisis will last, making some smart money moves to preserve your cash in the meantime can help you stay afloat.

A version of this article originally appeared on Medscape.com.

Even before Atlanta had an official shelter-in-place order, patients at the private plastic surgery practice of Nicholas Jones, MD, began canceling and rescheduled planned procedures.

After a few weeks, Dr. Jones, aged 40 years, stopped seeing patients entirely, but as a self-employed independent contractor, that means he’d lost most of his income. Dr. Jones still makes some money via a wound care job at a local nursing home, but he’s concerned that job may also be eliminated.

“I’m not hurting yet,” he said. “But I’m preparing for the worst possible scenario.”

In preparation, he and his fiancé have cut back on extraneous expenses like Uber Eats, magazine subscriptions, and streaming music services. Even though he has a 6-month emergency fund, Jones has reached out to utility companies, mortgage lenders, and student loan servicers to find out about any programs they offer to people who’ve suffered financially from the coronavirus crisis.

He’s also considered traveling to one of the COVID-19 epicenters – he has family in New Orleans and Chicago – to work in a hospital there. Jones has trauma experience and is double-boarded in general and plastic surgery.

“I could provide relief to those in need and also float through this troubled time with some financial relief,” he said.

Whereas much of the world’s attention has been on physicians who are on the front line and working around the clock in hospitals to help COVID-19 patients, thousands of other physicians are experiencing the opposite phenomenon – a slowdown or even stoppage of work (and income) altogether.

Many practices are temporarily closing to meet social distancing requirements, and some may end up closed for months, leaving doctors without a source of income. Even among those practices that remain open, the number of patients has declined as people avoid going to the office unless they absolutely have to.

At the same time, doctors in two-income households may have a spouse experiencing a job loss or income decline. Nearly 10 million Americans applied for unemployment benefits in the last 2 weeks of March, the largest number on record.

Still, while there’s uncertainty around how long the coronavirus crisis will last, experts agree that at some point America will return to a “new normal” and business operations will begin to reopen. For physicians experiencing a reduction in income who, like Jones, have an emergency fund with a few months’ worth of expenses, now’s the time to tap into it. (Or if you still have income, now’s the time to focus on growing that emergency fund to give yourself an even bigger safety net.)

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here’s how to stay afloat in the near term:
 

Cut back on expenses

Some household spending has naturally tapered off for many families because social distancing restrictions reduce spending on eating out, travel, and other leisure activities. But this is also an opportunity to look for other ways to reduce spending. Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need.

Some gyms are not allowing membership termination right now, but it pays to ask. If a service you’re not using won’t facilitate the cancellation, call your credit card company to dispute and stop the charges, and report them to the Better Business Bureau.

You should also stop contributing to nonemergency savings accounts such as your retirement fund or your children’s college funds.

“A lot of people are hesitant to stop their automatic savings if they’ve been maxing out their 401(k) contribution or 529 accounts,” says Andrew Musbach, a certified financial planner and cofounder of MD Wealth Management in Chelsea, Mich. “But if you’re thinking long term, the reality is that missing a couple of months won’t make or break a plan. Cutting back on the amount you’re saving in the short term will increase your cash flow and is a good way to make ends meet.”
 

Take advantage of regulatory changes

Although many physicians won’t qualify for direct payments via the Coronavirus Aid Relief and Economic Security (CARES) Act (the $1,200 payments to individuals start phasing out once income hits $75,000 and disappear entirely for those making more than $99,000), there are other provisions in the stimulus bill that may help physicians. The bill, for example, boosts state unemployment payments by $600 per week for the next 4 months, meaning qualified workers could receive an average of nearly $1,000 per week, depending on their state, and there are new provisions providing unemployment payments to self-employed and contract workers.

The CARES Act also includes a break for federal student loan holders. Under that rule, you can skip your payments through September without incurring additional interest. Physicians in the loan forgiveness program will still get credit for payments skipped during this program.

Separately, the IRS has extended the tax deadline from April 15 to July 15, which means not only do you not have to file your taxes until then, you also don’t have to pay any taxes you owe until mid-July. The deadline for first quarter estimated tax payments has also moved to July 15. (If you’re expecting a refund, however, you should file ASAP, since the IRS will typically issue those within a few weeks of receiving your returns.)
 

Tap your home equity – if you’re planning to stay put

If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Interest rates have fallen recently amid economic turbulence, so if you haven’t refinanced recently you may be able to shave your monthly payment. If you need cash, a cash-out refinance, home equity line of credit, or a reverse mortgage (available if you’re over age 62) are among the lowest-cost ways to borrow.

“With interest rates so low, there can be a lot of benefit to refinancing and leveraging your house, especially if you’re planning to stay there,” says Jamie Hopkins, a director at the Carson Group. “The challenge is if you’re planning to move in the next few years. There’s a real risk that the housing market could go down in the next couple of years, and if you’re planning to sell, there’s a risk that you might not get back what you borrowed.”
 

Communicate early with your bank or landlord

If you don’t have the income to refinance, and you think you’re going to run into trouble making your housing payment, you should let your bank or landlord know as soon as possible. The CARES Act allows homeowners with federally backed mortgages to obtain a 180-day postponement of mortgage payments because of COVID-19 financial hardship, with the potential to extend for another 180 days. It also bans eviction by landlords with federal mortgages for 120 days.

Even if you don’t have a federally backed mortgage, you should still get in touch with your lender. Many mortgage servicers have their own forbearance programs for borrowers who can prove a temporary financial hardship. (Some banks are also waiving fees on early withdrawals on CDs and giving cardholders a reprieve on credit card payments.) Commercial landlords are also working with struggling tenants, so you may also be able to get some relief on your office lease as well.

“All of the lenders are setting up helplines for people affected,” says Amy Guerich, a partner with Stepp & Rothwell, a Kansas City–based financial planning firm. “The best thing you can do is contact them right away if you think that you’re going to have a problem vs. just letting the bills go.”
 

Consider retirement account withdrawals

Standard personal finance advice holds that you should exhaust all other options before pulling money out of your retirement account because of the high penalties for early withdrawals and because money removed from retirement accounts is no longer compounding over time.

Still, the CARES act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. You’ll owe ordinary income taxes on the withdrawal, but you have 3 years to pay them or to return the money to your retirement account.

“That’s a great relief provision, especially for higher-income physicians who might have a higher 401(k) balance,” said Jamie Hopkins.
 

Be smart about credit cards

Although using credit cards that you can’t pay off every month is typically an expensive way to access money, getting a new card with a low or zero percent introductory rate is a short-term strategy to consider when you’ve exhausted other options. If you have good credit, you may be able to qualify for a credit card with a 0% introductory interest rate on new transactions. Pay close attention to the fine print, including the cap on the balance you can carry without interest and whether you’ll be required to make minimum payments.

The average 0% credit card offer is for 11 months, but there are some cards that can extend the offer for up to a year-and-a-half. If you choose to use this strategy, you’ll need a plan to pay off the entire balance before the introductory period ends. If there’s a balance remaining once the rate resets, you may end up owing deferred interest on it.

The financial ramifications of the coronavirus can feel overwhelming, but it’s important not to panic. While it remains unclear how long the current crisis will last, making some smart money moves to preserve your cash in the meantime can help you stay afloat.

A version of this article originally appeared on Medscape.com.

Even before Atlanta had an official shelter-in-place order, patients at the private plastic surgery practice of Nicholas Jones, MD, began canceling and rescheduled planned procedures.

After a few weeks, Dr. Jones, aged 40 years, stopped seeing patients entirely, but as a self-employed independent contractor, that means he’d lost most of his income. Dr. Jones still makes some money via a wound care job at a local nursing home, but he’s concerned that job may also be eliminated.

“I’m not hurting yet,” he said. “But I’m preparing for the worst possible scenario.”

In preparation, he and his fiancé have cut back on extraneous expenses like Uber Eats, magazine subscriptions, and streaming music services. Even though he has a 6-month emergency fund, Jones has reached out to utility companies, mortgage lenders, and student loan servicers to find out about any programs they offer to people who’ve suffered financially from the coronavirus crisis.

He’s also considered traveling to one of the COVID-19 epicenters – he has family in New Orleans and Chicago – to work in a hospital there. Jones has trauma experience and is double-boarded in general and plastic surgery.

“I could provide relief to those in need and also float through this troubled time with some financial relief,” he said.

Whereas much of the world’s attention has been on physicians who are on the front line and working around the clock in hospitals to help COVID-19 patients, thousands of other physicians are experiencing the opposite phenomenon – a slowdown or even stoppage of work (and income) altogether.

Many practices are temporarily closing to meet social distancing requirements, and some may end up closed for months, leaving doctors without a source of income. Even among those practices that remain open, the number of patients has declined as people avoid going to the office unless they absolutely have to.

At the same time, doctors in two-income households may have a spouse experiencing a job loss or income decline. Nearly 10 million Americans applied for unemployment benefits in the last 2 weeks of March, the largest number on record.

Still, while there’s uncertainty around how long the coronavirus crisis will last, experts agree that at some point America will return to a “new normal” and business operations will begin to reopen. For physicians experiencing a reduction in income who, like Jones, have an emergency fund with a few months’ worth of expenses, now’s the time to tap into it. (Or if you still have income, now’s the time to focus on growing that emergency fund to give yourself an even bigger safety net.)

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here’s how to stay afloat in the near term:
 

Cut back on expenses

Some household spending has naturally tapered off for many families because social distancing restrictions reduce spending on eating out, travel, and other leisure activities. But this is also an opportunity to look for other ways to reduce spending. Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need.

Some gyms are not allowing membership termination right now, but it pays to ask. If a service you’re not using won’t facilitate the cancellation, call your credit card company to dispute and stop the charges, and report them to the Better Business Bureau.

You should also stop contributing to nonemergency savings accounts such as your retirement fund or your children’s college funds.

“A lot of people are hesitant to stop their automatic savings if they’ve been maxing out their 401(k) contribution or 529 accounts,” says Andrew Musbach, a certified financial planner and cofounder of MD Wealth Management in Chelsea, Mich. “But if you’re thinking long term, the reality is that missing a couple of months won’t make or break a plan. Cutting back on the amount you’re saving in the short term will increase your cash flow and is a good way to make ends meet.”
 

Take advantage of regulatory changes

Although many physicians won’t qualify for direct payments via the Coronavirus Aid Relief and Economic Security (CARES) Act (the $1,200 payments to individuals start phasing out once income hits $75,000 and disappear entirely for those making more than $99,000), there are other provisions in the stimulus bill that may help physicians. The bill, for example, boosts state unemployment payments by $600 per week for the next 4 months, meaning qualified workers could receive an average of nearly $1,000 per week, depending on their state, and there are new provisions providing unemployment payments to self-employed and contract workers.

The CARES Act also includes a break for federal student loan holders. Under that rule, you can skip your payments through September without incurring additional interest. Physicians in the loan forgiveness program will still get credit for payments skipped during this program.

Separately, the IRS has extended the tax deadline from April 15 to July 15, which means not only do you not have to file your taxes until then, you also don’t have to pay any taxes you owe until mid-July. The deadline for first quarter estimated tax payments has also moved to July 15. (If you’re expecting a refund, however, you should file ASAP, since the IRS will typically issue those within a few weeks of receiving your returns.)
 

Tap your home equity – if you’re planning to stay put

If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Interest rates have fallen recently amid economic turbulence, so if you haven’t refinanced recently you may be able to shave your monthly payment. If you need cash, a cash-out refinance, home equity line of credit, or a reverse mortgage (available if you’re over age 62) are among the lowest-cost ways to borrow.

“With interest rates so low, there can be a lot of benefit to refinancing and leveraging your house, especially if you’re planning to stay there,” says Jamie Hopkins, a director at the Carson Group. “The challenge is if you’re planning to move in the next few years. There’s a real risk that the housing market could go down in the next couple of years, and if you’re planning to sell, there’s a risk that you might not get back what you borrowed.”
 

Communicate early with your bank or landlord

If you don’t have the income to refinance, and you think you’re going to run into trouble making your housing payment, you should let your bank or landlord know as soon as possible. The CARES Act allows homeowners with federally backed mortgages to obtain a 180-day postponement of mortgage payments because of COVID-19 financial hardship, with the potential to extend for another 180 days. It also bans eviction by landlords with federal mortgages for 120 days.

Even if you don’t have a federally backed mortgage, you should still get in touch with your lender. Many mortgage servicers have their own forbearance programs for borrowers who can prove a temporary financial hardship. (Some banks are also waiving fees on early withdrawals on CDs and giving cardholders a reprieve on credit card payments.) Commercial landlords are also working with struggling tenants, so you may also be able to get some relief on your office lease as well.

“All of the lenders are setting up helplines for people affected,” says Amy Guerich, a partner with Stepp & Rothwell, a Kansas City–based financial planning firm. “The best thing you can do is contact them right away if you think that you’re going to have a problem vs. just letting the bills go.”
 

Consider retirement account withdrawals

Standard personal finance advice holds that you should exhaust all other options before pulling money out of your retirement account because of the high penalties for early withdrawals and because money removed from retirement accounts is no longer compounding over time.

Still, the CARES act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. You’ll owe ordinary income taxes on the withdrawal, but you have 3 years to pay them or to return the money to your retirement account.

“That’s a great relief provision, especially for higher-income physicians who might have a higher 401(k) balance,” said Jamie Hopkins.
 

Be smart about credit cards

Although using credit cards that you can’t pay off every month is typically an expensive way to access money, getting a new card with a low or zero percent introductory rate is a short-term strategy to consider when you’ve exhausted other options. If you have good credit, you may be able to qualify for a credit card with a 0% introductory interest rate on new transactions. Pay close attention to the fine print, including the cap on the balance you can carry without interest and whether you’ll be required to make minimum payments.

The average 0% credit card offer is for 11 months, but there are some cards that can extend the offer for up to a year-and-a-half. If you choose to use this strategy, you’ll need a plan to pay off the entire balance before the introductory period ends. If there’s a balance remaining once the rate resets, you may end up owing deferred interest on it.

The financial ramifications of the coronavirus can feel overwhelming, but it’s important not to panic. While it remains unclear how long the current crisis will last, making some smart money moves to preserve your cash in the meantime can help you stay afloat.

A version of this article originally appeared on Medscape.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Tips to keep your finances healthy during COVID-19

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here are some tips on how to stay afloat in the near term. Cut back on expenses: Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need. Tap your home equity: If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Consider retirement account withdrawals: the CARES Act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. Read more.

Nursing homes overhaul infection control

The toll that COVID-19 has taken on nursing homes and their postacute and long-term care residents has a multilayered backstory involving underresourced organizational structures, inherent susceptibilities, minimally trained infection prevention staff, variable abilities to isolate and quarantine large numbers of patients and residents, and a lack of governmental support. “Nursing homes have been trying their best to combat this pandemic using the best infection control procedures they have, but blindfolded and with their hands tied behind their backs,” said Joseph G. Ouslander, MD, professor of geriatric medicine at Florida Atlantic University, Boca Raton. Experts in both long-term care and infectious disease said in interviews that, through the rest of the pandemic and beyond, nursing homes need the following: “Infection preventionists” to lead improvements in emergency preparedness and infection prevention and control, well-qualified and engaged medical directors, a survey/inspection process that focuses on education, and more resources and attention to structural reform. Read more.

WHO backtracks on asymptomatic SARS-CoV-2 transmission

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir on June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said. But on June 9 – following a day of criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.” Physicians and public health experts slammed the initial comments, saying that they created confusion. Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove’s initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is “not correct.” Read more.

E-cigs linked to smoking relapse

The use of electronic nicotine delivery systems is associated with increased risk of cigarette smoking relapse among former smokers, results from a large longitudinal cohort study demonstrated. The findings come from a survey of adult former smokers who participated in the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). Adjusted hazard ratio (AHR) analysis revealed that the use of electronic nicotine delivery systems was associated with significant risk of cigarette smoking relapse among recent former smokers (AHR 1.63) and among long-term former smokers (AHR 3.79). The use of other tobacco products was similarly associated with a significant risk for cigarette smoking relapse among recent former smokers (AHR 1.97) and among long-term former smokers (AHR 3.82). “For the many clinicians treating former smokers who have successfully quit all nicotine products, the implications are that use of [electronic nicotine delivery systems] should be discouraged, just as use of all other tobacco products is discouraged,” researchers led by Colm D. Everard, PhD, reported in a study published in JAMA Network Open. Read more.

Formula feeding leads to early weaning

Breastfed infants who receive formula in the hospital are more than twofold more likely to wean during the first year, compared with infants who are exclusively breastfed, according to research published online in Pediatrics. The finding is based on an analysis of data from over 8,000 infants in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). “Our study strengthens the evidence that formula supplementation of breastfed infants negatively affects breastfeeding duration,” said Marcia Burton McCoy, MPH, of the Minnesota Department of Health’s WIC, and Pamela Heggie, MD, of the University of Minnesota in Minneapolis. Read more.
 

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Tips to keep your finances healthy during COVID-19

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here are some tips on how to stay afloat in the near term. Cut back on expenses: Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need. Tap your home equity: If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Consider retirement account withdrawals: the CARES Act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. Read more.

Nursing homes overhaul infection control

The toll that COVID-19 has taken on nursing homes and their postacute and long-term care residents has a multilayered backstory involving underresourced organizational structures, inherent susceptibilities, minimally trained infection prevention staff, variable abilities to isolate and quarantine large numbers of patients and residents, and a lack of governmental support. “Nursing homes have been trying their best to combat this pandemic using the best infection control procedures they have, but blindfolded and with their hands tied behind their backs,” said Joseph G. Ouslander, MD, professor of geriatric medicine at Florida Atlantic University, Boca Raton. Experts in both long-term care and infectious disease said in interviews that, through the rest of the pandemic and beyond, nursing homes need the following: “Infection preventionists” to lead improvements in emergency preparedness and infection prevention and control, well-qualified and engaged medical directors, a survey/inspection process that focuses on education, and more resources and attention to structural reform. Read more.

WHO backtracks on asymptomatic SARS-CoV-2 transmission

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir on June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said. But on June 9 – following a day of criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.” Physicians and public health experts slammed the initial comments, saying that they created confusion. Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove’s initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is “not correct.” Read more.

E-cigs linked to smoking relapse

The use of electronic nicotine delivery systems is associated with increased risk of cigarette smoking relapse among former smokers, results from a large longitudinal cohort study demonstrated. The findings come from a survey of adult former smokers who participated in the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). Adjusted hazard ratio (AHR) analysis revealed that the use of electronic nicotine delivery systems was associated with significant risk of cigarette smoking relapse among recent former smokers (AHR 1.63) and among long-term former smokers (AHR 3.79). The use of other tobacco products was similarly associated with a significant risk for cigarette smoking relapse among recent former smokers (AHR 1.97) and among long-term former smokers (AHR 3.82). “For the many clinicians treating former smokers who have successfully quit all nicotine products, the implications are that use of [electronic nicotine delivery systems] should be discouraged, just as use of all other tobacco products is discouraged,” researchers led by Colm D. Everard, PhD, reported in a study published in JAMA Network Open. Read more.

Formula feeding leads to early weaning

Breastfed infants who receive formula in the hospital are more than twofold more likely to wean during the first year, compared with infants who are exclusively breastfed, according to research published online in Pediatrics. The finding is based on an analysis of data from over 8,000 infants in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). “Our study strengthens the evidence that formula supplementation of breastfed infants negatively affects breastfeeding duration,” said Marcia Burton McCoy, MPH, of the Minnesota Department of Health’s WIC, and Pamela Heggie, MD, of the University of Minnesota in Minneapolis. Read more.
 

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Tips to keep your finances healthy during COVID-19

If you’re among the more than half of Americans with less than 6 months of expenses saved for a rainy day, here are some tips on how to stay afloat in the near term. Cut back on expenses: Look through your credit card bills to see whether there are recurring payments you can cut, such as a payment to a gym that’s temporarily closed or a monthly subscription box that you don’t need. Tap your home equity: If you have good credit and still have some income, you might consider refinancing your home mortgage or opening a home equity line of credit. Consider retirement account withdrawals: the CARES Act has provisions making it less financially onerous to pull money from your retirement accounts. Under the new law, you can take a distribution of up to $100,000 from your IRA or 401(k) without having to pay the 10% early withdrawal penalty. Read more.

Nursing homes overhaul infection control

The toll that COVID-19 has taken on nursing homes and their postacute and long-term care residents has a multilayered backstory involving underresourced organizational structures, inherent susceptibilities, minimally trained infection prevention staff, variable abilities to isolate and quarantine large numbers of patients and residents, and a lack of governmental support. “Nursing homes have been trying their best to combat this pandemic using the best infection control procedures they have, but blindfolded and with their hands tied behind their backs,” said Joseph G. Ouslander, MD, professor of geriatric medicine at Florida Atlantic University, Boca Raton. Experts in both long-term care and infectious disease said in interviews that, through the rest of the pandemic and beyond, nursing homes need the following: “Infection preventionists” to lead improvements in emergency preparedness and infection prevention and control, well-qualified and engaged medical directors, a survey/inspection process that focuses on education, and more resources and attention to structural reform. Read more.

WHO backtracks on asymptomatic SARS-CoV-2 transmission

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir on June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said. But on June 9 – following a day of criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.” Physicians and public health experts slammed the initial comments, saying that they created confusion. Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove’s initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is “not correct.” Read more.

E-cigs linked to smoking relapse

The use of electronic nicotine delivery systems is associated with increased risk of cigarette smoking relapse among former smokers, results from a large longitudinal cohort study demonstrated. The findings come from a survey of adult former smokers who participated in the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). Adjusted hazard ratio (AHR) analysis revealed that the use of electronic nicotine delivery systems was associated with significant risk of cigarette smoking relapse among recent former smokers (AHR 1.63) and among long-term former smokers (AHR 3.79). The use of other tobacco products was similarly associated with a significant risk for cigarette smoking relapse among recent former smokers (AHR 1.97) and among long-term former smokers (AHR 3.82). “For the many clinicians treating former smokers who have successfully quit all nicotine products, the implications are that use of [electronic nicotine delivery systems] should be discouraged, just as use of all other tobacco products is discouraged,” researchers led by Colm D. Everard, PhD, reported in a study published in JAMA Network Open. Read more.

Formula feeding leads to early weaning

Breastfed infants who receive formula in the hospital are more than twofold more likely to wean during the first year, compared with infants who are exclusively breastfed, according to research published online in Pediatrics. The finding is based on an analysis of data from over 8,000 infants in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). “Our study strengthens the evidence that formula supplementation of breastfed infants negatively affects breastfeeding duration,” said Marcia Burton McCoy, MPH, of the Minnesota Department of Health’s WIC, and Pamela Heggie, MD, of the University of Minnesota in Minneapolis. Read more.
 

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Inflammatory bowel disease (IBD) does not seem to make patients any more likely to contract SARS-COV-2 or develop COVID-19, but a rapid review commissioned by the American Gastroenterological Association acknowledges that determination is based on limited evidence and IBD patients should nonetheless maintain remission to reduce their risk of relapse or hospitalization during the COVID-19 pandemic.

The AGA has published a clinical practice update based on that rapid review online in Gastroenterology (2020. doi: 10.1053/j.gastro.2020.04.012).

Because of the widespread use of immunosuppressive or immune-modifying drugs, “It is understandable why patients with Crohn’s disease and ulcerative colitis have specific concerns and potential for increased risk of infection with SARS-CoV-2,” wrote David T. Rubin, MD, AGAF, of the University of Chicago and colleagues in the expert commentary.

They noted that, while association between GI symptoms and COVID-19 RNA in stool samples isn’t clear, given the reports of GI symptoms in COVID-19 patients – ranging from 10% (JAMA. 2020:323:1061-9) to half of patients (Am J Gastroenterol. 2020;115:766-73) – “the clinical implications of this are quite important.” In IBD patients, changes in digestive symptoms without accompanying fever or respiratory symptoms can be monitored for symptoms that could merit testing for the virus as well as “trigger additional treatment adjustments.”

In accordance with the IOIBD (International Organization for the Study of Inflammatory Bowel Disease) consensus, the update noted that IBD patients should continue going to infusion centers for therapies, provided that the centers use a COVID-19 screening protocol.

Patients with IBD who contract COVID-19 seem more likely to be hospitalized for one or the other disease, but that’s based on data from the international SECURE-IBD registry that had 164 patients as of the writing of the update. The update provides guidance for three scenarios for IBD patients during the pandemic:

• Patients not infected with SARS-CoV-2 should maintain their IBD therapies to sustain remission and avoid relapses. “Aside from the obvious negative consequences of a relapse, relapsing IBD will strain available medical resources, may require steroid therapy or necessitate hospitalization, outcomes that are all much worse than the known risks of existing IBD therapies,” Dr. Rubin and colleagues noted.
• Patients who are infected but have no symptoms of COVID-19 should have their dosing of prednisone adjusted to less than 20 mg/day or switched to budesonide; suspend thiopurines, methotrexate, and tofacitinib; and delay dosing of monoclonal antibodies (anti–tumor necrosis factor [anti-TNF] drugs, ustekinumab, or vedolizumab) for 2 weeks while their symptoms for COVID-19 are monitored. “Restarting therapy after 2 weeks if the patient has not developed manifestations of COVID-19 is reasonable,” wrote Dr. Rubin and colleagues. Emerging serial testing should indicate antibody status, but the effectiveness of stool testing for SARS-CoV-2 in these cases “remains to be seen.”
• In the patient with confirmed COVID-19, adjustment of IBD therapy “is appropriate, based on the understanding of the immune activity of the therapy and whether that therapy may worsen outcomes with COVID-19,” the update stated. Therapy adjustment should focus on reducing immune suppression during the active viral infection. Some studies are evaluating anticytokine-based therapies as COVID-19 treatments, so continued anti-TNF therapies might prevent acute respiratory distress syndrome and multiorgan failure, Dr. Rubin and colleagues wrote. “However, in the absence of those data, guidance is currently based on deciding whether to hold or to continue specific IBD therapies.”

The update considers most IBD therapies, specifically aminosalicylates, topical rectal therapy, dietary management, and antibiotics “safe and may be continued,” and oral budesonide can be continued if it’s needed for ongoing IBD control. However, corticosteroids “should be avoided and discontinued quickly.”

Likewise, during the acute stage of COVID-19, thiopurines, methotrexate, and tofacitinib should be discontinued, and anti-TNF drugs and ustekinumab should be stopped during viral illness. Holding vedolizumab during viral illness is also appropriate, according to the update, although the IOIBD group was uncertain if doing so was necessary.

If the IBD patient has digestive symptoms with COVID-19, ongoing supportive care of the COVID-19 is “reasonable,” but investigating the causes of the digestive symptoms “is critically important.” That should include ruling out enteric infections and confirming active inflammation with nonendoscopic testing. Endoscopy should be relegated to only urgent and emergent cases.

Management of IBD in COVID-19 patients also depends on disease severity. Safer therapies are indicated for mild disease, but withholding IBD therapy in moderate to severe cases may not be practical. “In this setting, the risks and benefits of escalating IBD therapy must be carefully weighed against the severity of the COVID-19,” Dr. Rubin and colleagues noted.

In hospitalized patients with severe COVID-19 and poor prognoses, “IBD therapy will likely take a back seat,” the update stated, although COVID-19 therapies should take the concomitant IBD into account. In patients with milder cases of COVID-19, IBD management should focus on acute manifestations, but intravenous steroid therapy shouldn’t exceed 3 days. The update urged providers to submit cases of IBD and confirmed COVID-19 to the SECURE-IBD registry at COVIDIBD.org.

Dr. Rubin disclosed financial relationships with AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene/Syneos, Gilead Sciences, Takeda, and many other pharmaceutical companies. Coauthors disclosed relationships with those companies and Medimmune, Novus Therapeutics, Osiris Therapeutics, RedHill Biopharma, Sanofi-Aventis, UCB Pharma, and multiple other pharmaceutical companies.

SOURCE: Rubin DT, et al. Gastroenterology. 2020:  doi: 10.1053/j.gastro.2020.04.012

Inflammatory bowel disease (IBD) does not seem to make patients any more likely to contract SARS-COV-2 or develop COVID-19, but a rapid review commissioned by the American Gastroenterological Association acknowledges that determination is based on limited evidence and IBD patients should nonetheless maintain remission to reduce their risk of relapse or hospitalization during the COVID-19 pandemic.

The AGA has published a clinical practice update based on that rapid review online in Gastroenterology (2020. doi: 10.1053/j.gastro.2020.04.012).

Because of the widespread use of immunosuppressive or immune-modifying drugs, “It is understandable why patients with Crohn’s disease and ulcerative colitis have specific concerns and potential for increased risk of infection with SARS-CoV-2,” wrote David T. Rubin, MD, AGAF, of the University of Chicago and colleagues in the expert commentary.

They noted that, while association between GI symptoms and COVID-19 RNA in stool samples isn’t clear, given the reports of GI symptoms in COVID-19 patients – ranging from 10% (JAMA. 2020:323:1061-9) to half of patients (Am J Gastroenterol. 2020;115:766-73) – “the clinical implications of this are quite important.” In IBD patients, changes in digestive symptoms without accompanying fever or respiratory symptoms can be monitored for symptoms that could merit testing for the virus as well as “trigger additional treatment adjustments.”

In accordance with the IOIBD (International Organization for the Study of Inflammatory Bowel Disease) consensus, the update noted that IBD patients should continue going to infusion centers for therapies, provided that the centers use a COVID-19 screening protocol.

Patients with IBD who contract COVID-19 seem more likely to be hospitalized for one or the other disease, but that’s based on data from the international SECURE-IBD registry that had 164 patients as of the writing of the update. The update provides guidance for three scenarios for IBD patients during the pandemic:

• Patients not infected with SARS-CoV-2 should maintain their IBD therapies to sustain remission and avoid relapses. “Aside from the obvious negative consequences of a relapse, relapsing IBD will strain available medical resources, may require steroid therapy or necessitate hospitalization, outcomes that are all much worse than the known risks of existing IBD therapies,” Dr. Rubin and colleagues noted.
• Patients who are infected but have no symptoms of COVID-19 should have their dosing of prednisone adjusted to less than 20 mg/day or switched to budesonide; suspend thiopurines, methotrexate, and tofacitinib; and delay dosing of monoclonal antibodies (anti–tumor necrosis factor [anti-TNF] drugs, ustekinumab, or vedolizumab) for 2 weeks while their symptoms for COVID-19 are monitored. “Restarting therapy after 2 weeks if the patient has not developed manifestations of COVID-19 is reasonable,” wrote Dr. Rubin and colleagues. Emerging serial testing should indicate antibody status, but the effectiveness of stool testing for SARS-CoV-2 in these cases “remains to be seen.”
• In the patient with confirmed COVID-19, adjustment of IBD therapy “is appropriate, based on the understanding of the immune activity of the therapy and whether that therapy may worsen outcomes with COVID-19,” the update stated. Therapy adjustment should focus on reducing immune suppression during the active viral infection. Some studies are evaluating anticytokine-based therapies as COVID-19 treatments, so continued anti-TNF therapies might prevent acute respiratory distress syndrome and multiorgan failure, Dr. Rubin and colleagues wrote. “However, in the absence of those data, guidance is currently based on deciding whether to hold or to continue specific IBD therapies.”

The update considers most IBD therapies, specifically aminosalicylates, topical rectal therapy, dietary management, and antibiotics “safe and may be continued,” and oral budesonide can be continued if it’s needed for ongoing IBD control. However, corticosteroids “should be avoided and discontinued quickly.”

Likewise, during the acute stage of COVID-19, thiopurines, methotrexate, and tofacitinib should be discontinued, and anti-TNF drugs and ustekinumab should be stopped during viral illness. Holding vedolizumab during viral illness is also appropriate, according to the update, although the IOIBD group was uncertain if doing so was necessary.

If the IBD patient has digestive symptoms with COVID-19, ongoing supportive care of the COVID-19 is “reasonable,” but investigating the causes of the digestive symptoms “is critically important.” That should include ruling out enteric infections and confirming active inflammation with nonendoscopic testing. Endoscopy should be relegated to only urgent and emergent cases.

Management of IBD in COVID-19 patients also depends on disease severity. Safer therapies are indicated for mild disease, but withholding IBD therapy in moderate to severe cases may not be practical. “In this setting, the risks and benefits of escalating IBD therapy must be carefully weighed against the severity of the COVID-19,” Dr. Rubin and colleagues noted.

In hospitalized patients with severe COVID-19 and poor prognoses, “IBD therapy will likely take a back seat,” the update stated, although COVID-19 therapies should take the concomitant IBD into account. In patients with milder cases of COVID-19, IBD management should focus on acute manifestations, but intravenous steroid therapy shouldn’t exceed 3 days. The update urged providers to submit cases of IBD and confirmed COVID-19 to the SECURE-IBD registry at COVIDIBD.org.

Dr. Rubin disclosed financial relationships with AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene/Syneos, Gilead Sciences, Takeda, and many other pharmaceutical companies. Coauthors disclosed relationships with those companies and Medimmune, Novus Therapeutics, Osiris Therapeutics, RedHill Biopharma, Sanofi-Aventis, UCB Pharma, and multiple other pharmaceutical companies.

SOURCE: Rubin DT, et al. Gastroenterology. 2020:  doi: 10.1053/j.gastro.2020.04.012

Inflammatory bowel disease (IBD) does not seem to make patients any more likely to contract SARS-COV-2 or develop COVID-19, but a rapid review commissioned by the American Gastroenterological Association acknowledges that determination is based on limited evidence and IBD patients should nonetheless maintain remission to reduce their risk of relapse or hospitalization during the COVID-19 pandemic.

The AGA has published a clinical practice update based on that rapid review online in Gastroenterology (2020. doi: 10.1053/j.gastro.2020.04.012).

Because of the widespread use of immunosuppressive or immune-modifying drugs, “It is understandable why patients with Crohn’s disease and ulcerative colitis have specific concerns and potential for increased risk of infection with SARS-CoV-2,” wrote David T. Rubin, MD, AGAF, of the University of Chicago and colleagues in the expert commentary.

They noted that, while association between GI symptoms and COVID-19 RNA in stool samples isn’t clear, given the reports of GI symptoms in COVID-19 patients – ranging from 10% (JAMA. 2020:323:1061-9) to half of patients (Am J Gastroenterol. 2020;115:766-73) – “the clinical implications of this are quite important.” In IBD patients, changes in digestive symptoms without accompanying fever or respiratory symptoms can be monitored for symptoms that could merit testing for the virus as well as “trigger additional treatment adjustments.”

In accordance with the IOIBD (International Organization for the Study of Inflammatory Bowel Disease) consensus, the update noted that IBD patients should continue going to infusion centers for therapies, provided that the centers use a COVID-19 screening protocol.

Patients with IBD who contract COVID-19 seem more likely to be hospitalized for one or the other disease, but that’s based on data from the international SECURE-IBD registry that had 164 patients as of the writing of the update. The update provides guidance for three scenarios for IBD patients during the pandemic:

• Patients not infected with SARS-CoV-2 should maintain their IBD therapies to sustain remission and avoid relapses. “Aside from the obvious negative consequences of a relapse, relapsing IBD will strain available medical resources, may require steroid therapy or necessitate hospitalization, outcomes that are all much worse than the known risks of existing IBD therapies,” Dr. Rubin and colleagues noted.
• Patients who are infected but have no symptoms of COVID-19 should have their dosing of prednisone adjusted to less than 20 mg/day or switched to budesonide; suspend thiopurines, methotrexate, and tofacitinib; and delay dosing of monoclonal antibodies (anti–tumor necrosis factor [anti-TNF] drugs, ustekinumab, or vedolizumab) for 2 weeks while their symptoms for COVID-19 are monitored. “Restarting therapy after 2 weeks if the patient has not developed manifestations of COVID-19 is reasonable,” wrote Dr. Rubin and colleagues. Emerging serial testing should indicate antibody status, but the effectiveness of stool testing for SARS-CoV-2 in these cases “remains to be seen.”
• In the patient with confirmed COVID-19, adjustment of IBD therapy “is appropriate, based on the understanding of the immune activity of the therapy and whether that therapy may worsen outcomes with COVID-19,” the update stated. Therapy adjustment should focus on reducing immune suppression during the active viral infection. Some studies are evaluating anticytokine-based therapies as COVID-19 treatments, so continued anti-TNF therapies might prevent acute respiratory distress syndrome and multiorgan failure, Dr. Rubin and colleagues wrote. “However, in the absence of those data, guidance is currently based on deciding whether to hold or to continue specific IBD therapies.”

The update considers most IBD therapies, specifically aminosalicylates, topical rectal therapy, dietary management, and antibiotics “safe and may be continued,” and oral budesonide can be continued if it’s needed for ongoing IBD control. However, corticosteroids “should be avoided and discontinued quickly.”

Likewise, during the acute stage of COVID-19, thiopurines, methotrexate, and tofacitinib should be discontinued, and anti-TNF drugs and ustekinumab should be stopped during viral illness. Holding vedolizumab during viral illness is also appropriate, according to the update, although the IOIBD group was uncertain if doing so was necessary.

If the IBD patient has digestive symptoms with COVID-19, ongoing supportive care of the COVID-19 is “reasonable,” but investigating the causes of the digestive symptoms “is critically important.” That should include ruling out enteric infections and confirming active inflammation with nonendoscopic testing. Endoscopy should be relegated to only urgent and emergent cases.

Management of IBD in COVID-19 patients also depends on disease severity. Safer therapies are indicated for mild disease, but withholding IBD therapy in moderate to severe cases may not be practical. “In this setting, the risks and benefits of escalating IBD therapy must be carefully weighed against the severity of the COVID-19,” Dr. Rubin and colleagues noted.

In hospitalized patients with severe COVID-19 and poor prognoses, “IBD therapy will likely take a back seat,” the update stated, although COVID-19 therapies should take the concomitant IBD into account. In patients with milder cases of COVID-19, IBD management should focus on acute manifestations, but intravenous steroid therapy shouldn’t exceed 3 days. The update urged providers to submit cases of IBD and confirmed COVID-19 to the SECURE-IBD registry at COVIDIBD.org.

Dr. Rubin disclosed financial relationships with AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene/Syneos, Gilead Sciences, Takeda, and many other pharmaceutical companies. Coauthors disclosed relationships with those companies and Medimmune, Novus Therapeutics, Osiris Therapeutics, RedHill Biopharma, Sanofi-Aventis, UCB Pharma, and multiple other pharmaceutical companies.

SOURCE: Rubin DT, et al. Gastroenterology. 2020:  doi: 10.1053/j.gastro.2020.04.012

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

A version of this article originally appeared on Medscape.com.

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

A version of this article originally appeared on Medscape.com.

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

A version of this article originally appeared on Medscape.com.

A World Health Organization (WHO) official is walking back her comments characterizing the spread of SARS-CoV-2 by asymptomatic individuals as “rare.”

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said.

Suppressing symptomatic cases, on the other hand, would result in a “drastic reduction” in transmission, she noted. “But from the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual,” she said.

But on June 9 – following a day of confusion and criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.”

Between 6% and 41% of individuals may be asymptomatic based on estimates, she acknowledged.“What we need to better understand is how many of the people in the population don’t have symptoms, and separately, how many of those individuals go on to transmit to others,” she said.

Dr. Van Kerkhove also emphasized that her initial comments were made in response to a question raised at the press conference, and called it a misunderstanding. “I wasn’t stating a policy of WHO or anything like that,” she said. “I was just trying to articulate what we know.”

The phrase “very rare” referred to a subset of studies and reports WHO had received from its member states following asymptomatic individuals with COVID-19. “I was referring to some detailed investigations, cluster investigations, case contact tracing, where we had reports from member states saying that, when we follow asymptomatic cases, it’s very rare – and I used the phrase very rare – that we found a secondary transmission,” she said.

Dr. Van Kerkhove’s initial comments drew criticism from medical and public health professionals, who said the statement was “confusing” and communicated poorly.

Eric J. Topol, MD, tweeted that WHO had “engendered considerable confusion” with the comments about asymptomatic individuals rarely transmitting SARS-CoV-2. Dr. Topol, the author of a recent analysis published in Annals of Internal Medicine that suggested as many as 40%-45% of COVID-19 cases may be asymptomatic, said that it was not possible to determine whether asymptomatic individuals in the cohorts he studied were capable of spread like pre-symptomatic individuals. “We only know the viral loads are similar from multiple reports. And we do know some spread occurs from [asymptomatic] people,” he said.

Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, said in a tweet that he believed WHO made “an irresponsible statement even though it was based on legitimate observations.” Reports by Member States do not reach a “bar of rigor,” he said.

Natalie E. Dean, PhD, assistant professor of biostatistics at the University of Florida, tweeted that the initial comments by the WHO seemed to be trying to draw a distinction between asymptomatic individuals who never develop symptoms, and presymptomatic individuals who present as asymptomatic, but later develop symptoms. Finding that asymptomatic cases rarely transmit the virus could change how people exposed to those asymptomatic individuals are monitored, but “it seems more of scientific than practical interest,” she noted. “People without current symptoms could be infectious. Act accordingly.”

Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, also weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove's initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is "not correct." 

This article was updated 6/10/20.

A World Health Organization (WHO) official is walking back her comments characterizing the spread of SARS-CoV-2 by asymptomatic individuals as “rare.”

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said.

Suppressing symptomatic cases, on the other hand, would result in a “drastic reduction” in transmission, she noted. “But from the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual,” she said.

But on June 9 – following a day of confusion and criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.”

Between 6% and 41% of individuals may be asymptomatic based on estimates, she acknowledged.“What we need to better understand is how many of the people in the population don’t have symptoms, and separately, how many of those individuals go on to transmit to others,” she said.

Dr. Van Kerkhove also emphasized that her initial comments were made in response to a question raised at the press conference, and called it a misunderstanding. “I wasn’t stating a policy of WHO or anything like that,” she said. “I was just trying to articulate what we know.”

The phrase “very rare” referred to a subset of studies and reports WHO had received from its member states following asymptomatic individuals with COVID-19. “I was referring to some detailed investigations, cluster investigations, case contact tracing, where we had reports from member states saying that, when we follow asymptomatic cases, it’s very rare – and I used the phrase very rare – that we found a secondary transmission,” she said.

Dr. Van Kerkhove’s initial comments drew criticism from medical and public health professionals, who said the statement was “confusing” and communicated poorly.

Eric J. Topol, MD, tweeted that WHO had “engendered considerable confusion” with the comments about asymptomatic individuals rarely transmitting SARS-CoV-2. Dr. Topol, the author of a recent analysis published in Annals of Internal Medicine that suggested as many as 40%-45% of COVID-19 cases may be asymptomatic, said that it was not possible to determine whether asymptomatic individuals in the cohorts he studied were capable of spread like pre-symptomatic individuals. “We only know the viral loads are similar from multiple reports. And we do know some spread occurs from [asymptomatic] people,” he said.

Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, said in a tweet that he believed WHO made “an irresponsible statement even though it was based on legitimate observations.” Reports by Member States do not reach a “bar of rigor,” he said.

Natalie E. Dean, PhD, assistant professor of biostatistics at the University of Florida, tweeted that the initial comments by the WHO seemed to be trying to draw a distinction between asymptomatic individuals who never develop symptoms, and presymptomatic individuals who present as asymptomatic, but later develop symptoms. Finding that asymptomatic cases rarely transmit the virus could change how people exposed to those asymptomatic individuals are monitored, but “it seems more of scientific than practical interest,” she noted. “People without current symptoms could be infectious. Act accordingly.”

Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, also weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove's initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is "not correct." 

This article was updated 6/10/20.

A World Health Organization (WHO) official is walking back her comments characterizing the spread of SARS-CoV-2 by asymptomatic individuals as “rare.”

Maria Van Kerkhove, PhD, WHO’s COVID-19 technical lead and an infectious disease epidemiologist, caused a stir June 8 when she said that countries are reporting that many of their asymptomatic cases develop into cases of mild disease. For patients with truly asymptomatic disease, countries are “not finding secondary transmission onward. It’s very rare,” she said.

Suppressing symptomatic cases, on the other hand, would result in a “drastic reduction” in transmission, she noted. “But from the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual,” she said.

But on June 9 – following a day of confusion and criticism – Dr. Van Kerkhove sought to clarify her comments on asymptomatic transmission during a live social media Q&A. She noted that while “the majority of transmission that we know about” is through individuals with symptoms, “there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms – we don’t actually have that answer yet.”

Between 6% and 41% of individuals may be asymptomatic based on estimates, she acknowledged.“What we need to better understand is how many of the people in the population don’t have symptoms, and separately, how many of those individuals go on to transmit to others,” she said.

Dr. Van Kerkhove also emphasized that her initial comments were made in response to a question raised at the press conference, and called it a misunderstanding. “I wasn’t stating a policy of WHO or anything like that,” she said. “I was just trying to articulate what we know.”

The phrase “very rare” referred to a subset of studies and reports WHO had received from its member states following asymptomatic individuals with COVID-19. “I was referring to some detailed investigations, cluster investigations, case contact tracing, where we had reports from member states saying that, when we follow asymptomatic cases, it’s very rare – and I used the phrase very rare – that we found a secondary transmission,” she said.

Dr. Van Kerkhove’s initial comments drew criticism from medical and public health professionals, who said the statement was “confusing” and communicated poorly.

Eric J. Topol, MD, tweeted that WHO had “engendered considerable confusion” with the comments about asymptomatic individuals rarely transmitting SARS-CoV-2. Dr. Topol, the author of a recent analysis published in Annals of Internal Medicine that suggested as many as 40%-45% of COVID-19 cases may be asymptomatic, said that it was not possible to determine whether asymptomatic individuals in the cohorts he studied were capable of spread like pre-symptomatic individuals. “We only know the viral loads are similar from multiple reports. And we do know some spread occurs from [asymptomatic] people,” he said.

Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, said in a tweet that he believed WHO made “an irresponsible statement even though it was based on legitimate observations.” Reports by Member States do not reach a “bar of rigor,” he said.

Natalie E. Dean, PhD, assistant professor of biostatistics at the University of Florida, tweeted that the initial comments by the WHO seemed to be trying to draw a distinction between asymptomatic individuals who never develop symptoms, and presymptomatic individuals who present as asymptomatic, but later develop symptoms. Finding that asymptomatic cases rarely transmit the virus could change how people exposed to those asymptomatic individuals are monitored, but “it seems more of scientific than practical interest,” she noted. “People without current symptoms could be infectious. Act accordingly.”

Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, also weighed in on the controversial WHO comments, telling Good Morning America on June 10 that Dr. Van Kerkhove's initial statement that asymptomatic SARS-CoV-2 transmission is a rare event is "not correct." 

This article was updated 6/10/20.

Being aged older than 65 years was associated with the highest risk of people with rheumatic and musculoskeletal diseases (RMDs) needing hospital treatment for COVID-19, according to the first results to be reported from ReCoVery, the German national COVID-19 registry.

Older patients with RMDs were five times more likely than younger patients to be hospitalized if they tested positive for SARS‑CoV‑2 and developed COVID-19 (odds ratio, 5.1; 95% confidence interval, 2.3-11.4).

The likelihood of hospitalization was also significantly increased by the current or prior use of glucocorticoids (OR, 2.59; 95% CI, 1.2-5.4) and by the presence of cardiovascular disease (OR, 2.27; 95% CI, 1.2-5.4).

“The register is a joint initiative of the German Society for Rheumatology and the Justus Liebig University in Giessen,” explained Anne Regierer, MD, during a live session of the annual European Congress of Rheumatology, held online this year due to COVID-19.

“The current pandemic has changed all of our lives. For patients it brought a lot of uncertainty and fears,” said Dr. Regierer, of the German Rheumatism Research Center Berlin.

“The risk of SARS-CoV-2 infection in patients with inflammatory rheumatic diseases [IRD] is still largely unknown. We still don’t know whether they have a high risk of getting the infection or whether they have a higher risk of a severer case ... therefore there’s an urgent need to have data to generate evidence for the management of our patients.”

Launched at the end of March 2020, the German registry now includes data on 251 patients – 194 of whom have recovered – provided by more than 200 registered rheumatologists. The registry data have now been integrated into the EULAR COVID-19 Database, which is itself part of a global effort to better understand and optimally manage RMD patients during the pandemic.

“The data presented by Dr. Regierer looked at similar outcomes and found quite similar results, which is reassuring,” Kimme Hyrich, MD, PhD, professor of epidemiology at the University of Manchester (England) and a consultant rheumatologist in the Kellgren Centre for Rheumatology at Manchester University Hospitals NHS Foundation Trust, said in an interview.

“We are very grateful for this collaboration [with the German society and others]. Our first publication has looked at hospitalization, but with more data we may have the opportunity to look at less-common outcomes [e.g. death, other COVID complications] or within individual diseases or treatments. So far I don’t think we will come to a different conclusion,” observed Dr. Hyrich, who is on the steering committee for the EULAR COVID-19 Database.

“These initial data are reassuring in that the majority of cases of COVID reported to our database have recovered, including those who were hospitalized,” she said.

Current EULAR advice is to continue treatment with glucocorticoids in patients who are being chronically treated, but to use them at the lowest possible dose.

The objectives of this first analysis of the German registry was to provide a description of the patients who did and did not require hospitalization and those who needed ventilation, as well as look at possible risk factors for hospitalization.

Dr. Regierer reported that, of 192 patients they included – all with a positive lab test for SARS-CoV-2 – 128 (67%) did not require hospital admission. Of those that did (n = 64), 43 (22%) did not need ventilation and 21 (11%) did. Fifteen patients died, all of whom had been hospitalized, and all but one of them had needed ventilation.

Concerning the characteristics of the patients, those who needed hospital treatment with and without ventilation were older than those who were not admitted (70 vs. 65 vs. 54 years, respectively).

“Looking at the sexes, the gender distribution is also interesting. We see 69% females in the nonhospitalized patients, 65% of the inpatients without ventilation, but only 43% females in the ventilated patients. So in this group, the male patients are the majority,” Dr. Regierer observed.

Just over half of all patients in the nonhospitalized and the hospitalized without ventilation groups had IRD in remission, but those in the hospitalized with ventilation group less than one-fifth had their IRD under control.

“Of course we have to keep in mind the small sample sizes,” Dr. Regierer said, but the distribution of patients by disease type was “what you’d expect in clinical care.” The majority of patients in each of the three groups had RA (47%, 56%, and 57%), followed by psoriatic arthritis (19%, 7%, and 14%), axial spondyloarthritis (11%, 5%, and 0%), systemic lupus erythematosus (6%, 2%, and 0%), and vasculitis (1%, 5%, and 5%).

Patients who were hospitalized with and without ventilation were more likely to have more than one comorbidity than those who were not hospitalized with COVID-19.

“The most frequent comorbidity was cardiovascular disease with 58% and 76% in the inpatient groups,” Dr. Regierer reported. One-third of the nonhospitalized patients had a cardiovascular comorbidity.

“If we look at pulmonary disease, we see that 38% of the ventilator patients had an underlying pulmonary disease,” she added. This was in comparison with 19% of the hospitalized without ventilation and 13% of the nonhospitalized patients. Diabetes was another common comorbidity in hospitalized patients with (16%) and without (19%) ventilation versus just 2% of nonhospitalized patients. While these and other comorbidities such as chronic renal insufficiency were associated with higher odds ratios in the multivariate risk factor analysis, they did not reach statistical significance.

With regard to RMD treatments, more than 60% of patients in the hospitalized group had received treatment with glucocorticoids versus 37% of those who did not get admitted. No differences were seen for the other treatments.

Interestingly, “female sex, remission, and use of NSAIDs have an odds ratio smaller than 1. So there might be a lower risk of hospitalization associated with these factors,” Dr. Regierer said.

Dr. Regierer has received grant support and is part of speaker’s bureaus for a variety of pharmaceutical companies. Dr. Hyrich disclosed grant income from Bristol-Myers Squibb, UCB, and Pfizer, and receiving speaker fees from AbbVie.

Being aged older than 65 years was associated with the highest risk of people with rheumatic and musculoskeletal diseases (RMDs) needing hospital treatment for COVID-19, according to the first results to be reported from ReCoVery, the German national COVID-19 registry.

Older patients with RMDs were five times more likely than younger patients to be hospitalized if they tested positive for SARS‑CoV‑2 and developed COVID-19 (odds ratio, 5.1; 95% confidence interval, 2.3-11.4).

The likelihood of hospitalization was also significantly increased by the current or prior use of glucocorticoids (OR, 2.59; 95% CI, 1.2-5.4) and by the presence of cardiovascular disease (OR, 2.27; 95% CI, 1.2-5.4).

“The register is a joint initiative of the German Society for Rheumatology and the Justus Liebig University in Giessen,” explained Anne Regierer, MD, during a live session of the annual European Congress of Rheumatology, held online this year due to COVID-19.

“The current pandemic has changed all of our lives. For patients it brought a lot of uncertainty and fears,” said Dr. Regierer, of the German Rheumatism Research Center Berlin.

“The risk of SARS-CoV-2 infection in patients with inflammatory rheumatic diseases [IRD] is still largely unknown. We still don’t know whether they have a high risk of getting the infection or whether they have a higher risk of a severer case ... therefore there’s an urgent need to have data to generate evidence for the management of our patients.”

Launched at the end of March 2020, the German registry now includes data on 251 patients – 194 of whom have recovered – provided by more than 200 registered rheumatologists. The registry data have now been integrated into the EULAR COVID-19 Database, which is itself part of a global effort to better understand and optimally manage RMD patients during the pandemic.

“The data presented by Dr. Regierer looked at similar outcomes and found quite similar results, which is reassuring,” Kimme Hyrich, MD, PhD, professor of epidemiology at the University of Manchester (England) and a consultant rheumatologist in the Kellgren Centre for Rheumatology at Manchester University Hospitals NHS Foundation Trust, said in an interview.

“We are very grateful for this collaboration [with the German society and others]. Our first publication has looked at hospitalization, but with more data we may have the opportunity to look at less-common outcomes [e.g. death, other COVID complications] or within individual diseases or treatments. So far I don’t think we will come to a different conclusion,” observed Dr. Hyrich, who is on the steering committee for the EULAR COVID-19 Database.

“These initial data are reassuring in that the majority of cases of COVID reported to our database have recovered, including those who were hospitalized,” she said.

Current EULAR advice is to continue treatment with glucocorticoids in patients who are being chronically treated, but to use them at the lowest possible dose.

The objectives of this first analysis of the German registry was to provide a description of the patients who did and did not require hospitalization and those who needed ventilation, as well as look at possible risk factors for hospitalization.

Dr. Regierer reported that, of 192 patients they included – all with a positive lab test for SARS-CoV-2 – 128 (67%) did not require hospital admission. Of those that did (n = 64), 43 (22%) did not need ventilation and 21 (11%) did. Fifteen patients died, all of whom had been hospitalized, and all but one of them had needed ventilation.

Concerning the characteristics of the patients, those who needed hospital treatment with and without ventilation were older than those who were not admitted (70 vs. 65 vs. 54 years, respectively).

“Looking at the sexes, the gender distribution is also interesting. We see 69% females in the nonhospitalized patients, 65% of the inpatients without ventilation, but only 43% females in the ventilated patients. So in this group, the male patients are the majority,” Dr. Regierer observed.

Just over half of all patients in the nonhospitalized and the hospitalized without ventilation groups had IRD in remission, but those in the hospitalized with ventilation group less than one-fifth had their IRD under control.

“Of course we have to keep in mind the small sample sizes,” Dr. Regierer said, but the distribution of patients by disease type was “what you’d expect in clinical care.” The majority of patients in each of the three groups had RA (47%, 56%, and 57%), followed by psoriatic arthritis (19%, 7%, and 14%), axial spondyloarthritis (11%, 5%, and 0%), systemic lupus erythematosus (6%, 2%, and 0%), and vasculitis (1%, 5%, and 5%).

Patients who were hospitalized with and without ventilation were more likely to have more than one comorbidity than those who were not hospitalized with COVID-19.

“The most frequent comorbidity was cardiovascular disease with 58% and 76% in the inpatient groups,” Dr. Regierer reported. One-third of the nonhospitalized patients had a cardiovascular comorbidity.

“If we look at pulmonary disease, we see that 38% of the ventilator patients had an underlying pulmonary disease,” she added. This was in comparison with 19% of the hospitalized without ventilation and 13% of the nonhospitalized patients. Diabetes was another common comorbidity in hospitalized patients with (16%) and without (19%) ventilation versus just 2% of nonhospitalized patients. While these and other comorbidities such as chronic renal insufficiency were associated with higher odds ratios in the multivariate risk factor analysis, they did not reach statistical significance.

With regard to RMD treatments, more than 60% of patients in the hospitalized group had received treatment with glucocorticoids versus 37% of those who did not get admitted. No differences were seen for the other treatments.

Interestingly, “female sex, remission, and use of NSAIDs have an odds ratio smaller than 1. So there might be a lower risk of hospitalization associated with these factors,” Dr. Regierer said.

Dr. Regierer has received grant support and is part of speaker’s bureaus for a variety of pharmaceutical companies. Dr. Hyrich disclosed grant income from Bristol-Myers Squibb, UCB, and Pfizer, and receiving speaker fees from AbbVie.

Being aged older than 65 years was associated with the highest risk of people with rheumatic and musculoskeletal diseases (RMDs) needing hospital treatment for COVID-19, according to the first results to be reported from ReCoVery, the German national COVID-19 registry.

Older patients with RMDs were five times more likely than younger patients to be hospitalized if they tested positive for SARS‑CoV‑2 and developed COVID-19 (odds ratio, 5.1; 95% confidence interval, 2.3-11.4).

The likelihood of hospitalization was also significantly increased by the current or prior use of glucocorticoids (OR, 2.59; 95% CI, 1.2-5.4) and by the presence of cardiovascular disease (OR, 2.27; 95% CI, 1.2-5.4).

“The register is a joint initiative of the German Society for Rheumatology and the Justus Liebig University in Giessen,” explained Anne Regierer, MD, during a live session of the annual European Congress of Rheumatology, held online this year due to COVID-19.

“The current pandemic has changed all of our lives. For patients it brought a lot of uncertainty and fears,” said Dr. Regierer, of the German Rheumatism Research Center Berlin.

“The risk of SARS-CoV-2 infection in patients with inflammatory rheumatic diseases [IRD] is still largely unknown. We still don’t know whether they have a high risk of getting the infection or whether they have a higher risk of a severer case ... therefore there’s an urgent need to have data to generate evidence for the management of our patients.”

Launched at the end of March 2020, the German registry now includes data on 251 patients – 194 of whom have recovered – provided by more than 200 registered rheumatologists. The registry data have now been integrated into the EULAR COVID-19 Database, which is itself part of a global effort to better understand and optimally manage RMD patients during the pandemic.

“The data presented by Dr. Regierer looked at similar outcomes and found quite similar results, which is reassuring,” Kimme Hyrich, MD, PhD, professor of epidemiology at the University of Manchester (England) and a consultant rheumatologist in the Kellgren Centre for Rheumatology at Manchester University Hospitals NHS Foundation Trust, said in an interview.

“We are very grateful for this collaboration [with the German society and others]. Our first publication has looked at hospitalization, but with more data we may have the opportunity to look at less-common outcomes [e.g. death, other COVID complications] or within individual diseases or treatments. So far I don’t think we will come to a different conclusion,” observed Dr. Hyrich, who is on the steering committee for the EULAR COVID-19 Database.

“These initial data are reassuring in that the majority of cases of COVID reported to our database have recovered, including those who were hospitalized,” she said.

Current EULAR advice is to continue treatment with glucocorticoids in patients who are being chronically treated, but to use them at the lowest possible dose.

The objectives of this first analysis of the German registry was to provide a description of the patients who did and did not require hospitalization and those who needed ventilation, as well as look at possible risk factors for hospitalization.

Dr. Regierer reported that, of 192 patients they included – all with a positive lab test for SARS-CoV-2 – 128 (67%) did not require hospital admission. Of those that did (n = 64), 43 (22%) did not need ventilation and 21 (11%) did. Fifteen patients died, all of whom had been hospitalized, and all but one of them had needed ventilation.

Concerning the characteristics of the patients, those who needed hospital treatment with and without ventilation were older than those who were not admitted (70 vs. 65 vs. 54 years, respectively).

“Looking at the sexes, the gender distribution is also interesting. We see 69% females in the nonhospitalized patients, 65% of the inpatients without ventilation, but only 43% females in the ventilated patients. So in this group, the male patients are the majority,” Dr. Regierer observed.

Just over half of all patients in the nonhospitalized and the hospitalized without ventilation groups had IRD in remission, but those in the hospitalized with ventilation group less than one-fifth had their IRD under control.

“Of course we have to keep in mind the small sample sizes,” Dr. Regierer said, but the distribution of patients by disease type was “what you’d expect in clinical care.” The majority of patients in each of the three groups had RA (47%, 56%, and 57%), followed by psoriatic arthritis (19%, 7%, and 14%), axial spondyloarthritis (11%, 5%, and 0%), systemic lupus erythematosus (6%, 2%, and 0%), and vasculitis (1%, 5%, and 5%).

Patients who were hospitalized with and without ventilation were more likely to have more than one comorbidity than those who were not hospitalized with COVID-19.

“The most frequent comorbidity was cardiovascular disease with 58% and 76% in the inpatient groups,” Dr. Regierer reported. One-third of the nonhospitalized patients had a cardiovascular comorbidity.

“If we look at pulmonary disease, we see that 38% of the ventilator patients had an underlying pulmonary disease,” she added. This was in comparison with 19% of the hospitalized without ventilation and 13% of the nonhospitalized patients. Diabetes was another common comorbidity in hospitalized patients with (16%) and without (19%) ventilation versus just 2% of nonhospitalized patients. While these and other comorbidities such as chronic renal insufficiency were associated with higher odds ratios in the multivariate risk factor analysis, they did not reach statistical significance.

With regard to RMD treatments, more than 60% of patients in the hospitalized group had received treatment with glucocorticoids versus 37% of those who did not get admitted. No differences were seen for the other treatments.

Interestingly, “female sex, remission, and use of NSAIDs have an odds ratio smaller than 1. So there might be a lower risk of hospitalization associated with these factors,” Dr. Regierer said.

Dr. Regierer has received grant support and is part of speaker’s bureaus for a variety of pharmaceutical companies. Dr. Hyrich disclosed grant income from Bristol-Myers Squibb, UCB, and Pfizer, and receiving speaker fees from AbbVie.