30/04/2020
To all my MCAD friends!!!
If I go to the hospital, how will I explain to the doctors that I have immune issues, like MCAS, and will the doctors understand how to address it? What should I tell them?
Dr. Afrin is back on our page this week with another answer to your COVID-19/ MCAS question. His answer below:
In this age where the vast majority of the world's doctors have never even heard of MCAS let alone have any meaningful degree of familiarity with it, all one can do is inform the doctor that one has long had a chronic condition in which one's mast cells are excessively activated, causing a wide, multisystem range of inflammatory and allergic/reactive-type problems -- and thus that it's easily possible that the inflammatory reaction to the COVID-19 virus in that person's body may be even more heightened than a usual inflammatory reaction to a virus. (Importantly, note that this is a different concept than how *susceptible* one is to contracting an infection with the virus. An MCAS patient's *susceptibility* may be no significantly different than anybody else's susceptibility -- the virus is remarkably infective/contagious, no matter what type of patient one is talking about -- but an MCAS patient might be at higher risk for suffering an abnormally greater inflammatory *reaction* to the virus than anybody else's reaction.)
Plus, there of course may be risks in some (certainly not all) MCAS patients for reacting to some of the medication products which the patient's doctors may try to use to help control some of the symptoms (of the infection and of the body's inflammatory reaction to the infection). Thus, a courteous caution (by the patient or a family member or attendant) to the patient's doctors that if "unusually exuberant," and "difficult-to-control," inflammation is seen in the MCAS patient who has contracted a COVID-19 infection, then the doctors should *quickly* consider trials in the patient of medications aimed at suppressing mast cell activation, such as both H1 and H2 antihistamines, leukotriene inhibitors (such as montelukast or zafirlukast or zileuton), cromolyn (especially nebulized cromolyn if respiratory issues become significant), non-steroidal anti-inflammatory drugs (NSAIDs, unless the patient has previously demonstrated intolerance of such drugs), other types of anti-inflammatories (such as ketotifen and quercetin and luteolin and cannabidiol, among others), vitamin C (and possibly also vitamin D), benzodiazepines, and other mast-cell-targeting drugs.
In severe cases, certain very expensive anti-inflammatory drugs, such as JAK inhibitors and interleukin-6 antagonists and interleukin-1 antagonists, might be reasonable to try, too. Furthermore, although *ordinarily* a cautious approach to such medication trials ("one by one") is highly recommended in MCAS patients (because of (1) the challenges in identifying the particular culprit if multiple medications are started at the same time and the patient has a reaction, and (2) the risks in many MCAS patients in reacting to the excipients in medication products), in the setting of a rapidly worsening COVID-19 infection there just won't be the time for such caution and it will be OK to try initiating multiple such treatments (for example, H1 and H2 blockers and cromolyn and montelukast or zafirlukast or zileuton) all around, or at, the same time. Yes, if the patient then unfortunately demonstrates an adverse reaction to such a new cocktail, it will become quite a challenge to identify which component of the cocktail is causing the trouble, but, again, in the setting of a rapidly worsening COVID-19 infection, there often just won't be sufficient time to permit introduction of new medication products into a patient's regimen one by one.
If the patient is having trouble which the patient or close ones recognize, through the greater experience they have had with the patient than the patient's doctors at the time might have had, as more likely to be heightened symptoms of mast cell activation (MCAS) than any other process and yet the patient's present doctors do not appear to be giving serious consideration to the potentially important role that mast cell activation might be playing in the patient's total picture of illness at that time, then it would be very reasonable to ask the patient's doctors (again, courteously; there's just nothing productive that's ever going to be accomplished by getting hostile with any doctor, and such an approach could easily wind up being *counter* productive) for an urgent consultation with an immunologist, as there is some chance that immunologists (or allergists/immunologists) might be more familiar with MCAS than other types of doctors.
As is the case in general for MCAS patients, guidance for MCAS management in COVID-19-infected MCAS patients will need to be provided on an individualized basis.
We are happy to speak with the other emergency room medical physicians attending to any of our patients at this time who may be infected with COVID-19; all they need do is contact us.
Although we have to prioritize care for our established patients, we are happy to speak with other health care providers (doctors or otherwise, even if they are attending to patients who are not established with our own practice) who would like to understand more about mast cell activation disorders such as MCAS (for example, if they need urgent counsel on how to treat a COVID-19-infected patient who appears to be suffering severe inflammation from mast cell activation syndrome).
-Dr. Lawrence Afrin
*Editorial Note: Please note, this is the only headshot we have for Dr. Afrin at this time. While he is smiling in this photo, he is certainly not smiling about COVID-19. We would ideally like to use a non-smiling photo with these posts but this is the only photo we have. We are doing the best we can during these uncertain times. Thank you for your patience and understanding.