15/04/2020
I am sharing the article on ILD recently published in THE WEEK magazine. There are so many updates coming on covid19. This is a small attempt to reach out to people with ILD on what they need to know in covid19 scenario.
ILD TREATMENT DURING COVID19
(British Thoracic Society Advice for Managing Interstitial Lung Disease Patients during COVID-19 pandemic)
• Patients with ILD where possible opt for consultations by non-face to face means (USE ONLINE CONSULTATION)
• It remains unclear when normality will be restored. Going forward if situation worsens, all OPD activity is suspected cease in many places due to rise in admissions of patients with covid19
• Screening questions should be asked to ensure no suspected COVID-19 cases come to OPD. Ask about new cough, shortness of breath, fever, muscle aches and headaches.
• Get the patients attending OPD areas have their temperatures checked on arrival before reaching waiting area.
• ILD patients group is not thought to be at any greater specific COVID-19 risk due to their treatment. Their risks may be their age, underlying chest disease +/- other co morbidities. No need to alter drugs (PIRFENIDONE/NINTEDANIB) due to outbreak.
• ILD patients already on immunosuppression (IS) [immunosuppressive medicines= steroids, methotrexate (MTX), mycophenolate mofetil (MMF)] should continue taking them unless they are experiencing symptoms of infection, monitoring bloods dictate problems or side effects are an issue. The risk being if stopped or reduced their background disease control could slide.
• Try keeping IS dosing as low as possible to maintain disease stability. Any IS patient is at increased risk of infection. It is thus particularly important that ILD patients on IS socially isolate now and may need to do for some time to come.
• This group may experience a higher rate of post viral pneumonia or chance of clinical decline. At the first signs of deterioration or symptoms of a lower respiratory tract infection this group should seek early medical advice and if appropriate be treated early with broad spectrum antibiotics.
• They should seek early medical advice about when/if to pause IS drugs due to co-existing infection or follow advice.
• If ILD patients on IS require hospitalization usual guidance pausing IS drugs should be followed. This is usually stopping IS medication during infection and for usually 2 weeks after to permit recovery. Sometimes longer pauses are merited it is a case by case basis.
• For treating pulmonologist, it is of vital importance to carefully consider whether any IS in a patient has altered their trajectory.
1. Could a wean or stop be tried even for just a few months considering COVID-19 risks?
2. Can your sarcoid patient tolerate a slight drop in their IS?
3. Do they really need that higher dose of prednisolone now?
4. If original indication for IS was deemed weak, or, where there was a historical commencement of IS that is now weakly justified, it may be a good time to consider discontinuation of therapy.
• If the pandemic persists over a longer term safety blood monitoring may become more difficult to access regularly for patients. On a case by case basis consider if you can switch patients back to prednisolone (at last dose that controlled them) and stop 2nd line IS drugs such as Methotrexate or Mycophenolate Mofetil for next few months.
• General advice on steroids
1. If patients are on long term steroids usual dose increases (‘bump ups’) should be considered if ill to reduce risk of adrenal crisis.
2. ‘Bump down’ once recovery is established.
3. Patients are usually issued guidance around ‘bumps’ when given treatment initially.
