Clinical Recommendations for Patients with Underlying Medical Conditions: COVID-19
GUIDANCE AS OF APRIL 7, 2020
Based on currently available information and clinical expertise, older adults and people of any age with serious underlying medical conditions appear to be at higher risk for severe illness with COVID-19. Of 7,162 laboratory-confirmed cases of COVID-19 in the U.S., one or more underlying health conditions or risk factors were present in 38% overall and in 78% of those requiring ICU admission.(1) The most commonly reported conditions are chronic lung disease, cardiovascular disease, and diabetes.
These may include but are not limited to:(2)
- People aged 50 years and older, and in particular those aged 65 years and older.
- Chronic lung disease such as moderate/severe asthma, chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and cystic fibrosis (CF).
- Cardiovascular disease such as congestive heart failure (CHF), congenital heart disease, hypertension, coronary artery disease (CAD), and cerebrovascular disease.
- Other chronic conditions such as diabetes (particularly if poorly controlled), chronic kidney disease, or liver disease.
- Immunocompromising conditions such as cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, high dose chronic steroids, and other immune suppressing medication.
- Obesity, in particular a body mass index >40.
Information on COVID-19 in pregnancy is limited and to date does not suggest an increased risk for severe disease. However, pregnant women generally are at higher risk for viral respiratory infections (influenza, for example) due to immunological and physiological changes. It is also unknown if infection with SARS-CoV-2 is associated with adverse outcomes. However, high fever during the first trimester can increase risk of certain birth defects.
Clinical Recommendations for Health Care Providers
Based on data from other viral respiratory infections such as influenza, COVID-19 may cause exacerbations of chronic lung disease such as moderate or severe asthma or COPD and may lead to severe illness. In patients with underlying cardiovascular disease, COVID-19 infection may be associated with myocardial injury and impairment of cardiac function.(3) It is important to note that not all patients may present with typical symptoms of fever and cough and thus COVID-19 may not be suspected initially in patients presenting with exacerbations of chronic cardiac or pulmonary disease.
- Consider COVID-19 testing in the following situations even if typical symptoms (fever, cough) are absent:
- Acute decompensated heart failure.
- Acute exacerbations of COPD, CF, or IPF.
- Asthma exacerbations.
- Illness in immunocompromised patients, even if mild.
- Illness in patients aged ≥ 65 years and especially those ≥ 85 years.
- Illness in patients living in congregate care settings such as long-term care, correctional facilities, and shelters for people experiencing homelessness.
- Specific medication issues:
- For patients with asthma or COPD, steroids should be used per standard clinical guidelines both in the management of chronic stable disease and for acute exacerbations.(4)
- To date, there is no evidence that angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) are associated with improved or adverse outcomes in COVID-19 and should be continued in patients for whom they are currently prescribed for conditions where they are known to be beneficial.(5)
- To date there is no known association between the use of non-steroidal anti-inflammatory drugs (NSAIDs) and worsening COVID-19 symptoms. Patients or providers who wish to use alternative treatment options (such as acetaminophen) may choose to do so but there is currently no indication for discontinuing NSAID therapy in otherwise stable patients.
- Patients with underlying high-risk conditions should be advised to seek medical care quickly if they develop symptoms of illness and should practice social distancing.
- Every effort should be made to optimize medical therapy for patients with poorly controlled chronic diseases (such as diabetes, HIV).
- Patients who smoke should be strongly encouraged to quit. Visit Quitting Tobacco to learn more about free resources to help Minnesotans quit smoking, chewing, and vaping.
- For clinical questions regarding patients with suspected or confirmed COVID-19, CDC's COVID-19 Clinical Call Center is available 24 hours at 770-488-7100.
- MMWR: Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019. March 31, 2020 / 69
- CDC Clinician Outreach and Community Activity (COCA) Webinar: Underlying Medical Conditions and People at Higher Risk for Coronavirus Disease 2019 (COVID-19)
- Guo T et al. Clinical Implications of Fatal Outcomes of Patients with Coronavirus Disease 2019 (COVID-19). JAMA Cardiology, March 27, 2020. doi:10.1001/jamacardio.2020.1017
- ACAAI Statement of COVID-19 and Asthma, Allergy and Immune Deficiency Patients - 3-12-20
- HFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19