Clinical Recommendations for Patients with Underlying Medical Conditions: COVID-19
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. In a recent report 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) Among 1,482 patients hospitalized with COVID-19, the most commonly reported conditions were hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes (28.3%), and cardiovascular disease (27.8%).(2) Refer to CDC: People with Certain Medical Conditions for more information on underlying conditions and the risk of severe illness from COVID-19.
In general, the risk for severe illness from COVID-19 increases as you get older. People in their 50s are at higher risk than people in their 40s, and people in their 60s are at higher risk than people in their 50s. Eight out of 10 deaths from COVID-19 in the U.S. have been reported in adults aged 85 years and older; see CDC: Older Adults. In addition, people of any age with certain underlying health conditions are at increased risk of severe illness. These may include but are not limited to:
- Chronic kidney disease
- Chronic obstructive pulmonary disease (COPD)
- Serious heart conditions such as congestive heart failure, congenital heart disease, cardiomyopathy, coronary artery disease, and pulmonary hypertension
- Type 2 diabetes
- Immunocompromising conditions such as a solid organ transplant.
- Obesity, in particular a body mass index >30
- Hemoglobin disorders such as sickle cell disease
- Children who are medically complex (e.g., who have neurologic, genetic, or metabolic disorders or congenital heart disease) are at higher risk for severe illness from COVID-19 than other children
Other medical conditions that may increase the risk of severe illness
- Asthma (moderate to severe) and other chronic lung diseases such as cystic fibrosis or pulmonary fibrosis
- Cerebrovascular disease (affects blood vessels and blood supply to the brain)
- Immunocompromising conditions such as cancer treatments, bone marrow transplantation, immune deficiencies, HIV or AIDS (particularly if poorly controlled), use of high dose chronic steroids or other immune suppressing medications
- Neurological conditions such as dementia
- Liver disease
- Thalassemia (a blood disorder)
- Type 1 diabetes
Pregnant women may be at higher risk for severe illness from COVID-19. A CDC MMWR report suggested that pregnant women are at higher risk for hospitalization due to COVID-19 and to require ICU admission and mechanical ventilation.(3) The risk of death appeared to be the same for pregnant women and non-pregnant women. Pregnant women should be counseled about the possible risk for severe illness from COVID-19 and measures to prevent infection such as limiting interaction with others. Additional data are needed to further understand the risk to pregnant women from COVID-19. Pregnant health care workers should reach out to their supervisors and occupational health departments to discuss measures to limit their exposure to suspected or confirmed COVID-19 patients during higher risk procedures such as those that are aerosol generating; see Aerosol-Generating Procedures and Patients with Suspected or Confirmed COVID-19 (PDF). For additional information on COVID-19 and pregnancy, please see the American College of Obstetricians and Gynecologists Advisory at ACOG: Clinical Guidance; Novel Coronavirus 2019 (COVID-19).
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.(4) 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.(5)
- 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.(6,7)
- 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 — United States, February 12–March 28, 2020
- MMWR: Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 – COVID-NET, 14 States, March 1–30, 2020
- MMWR: Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status – United States, January 22–June 7, 2020
- Guo T et al. Cardiovascular 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
- Fosbøl E et al. Association of Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker Use With COVID-19 Diagnosis and Mortality. JAMA 2020;324(2):168-177. Doi:10.1001/jama.2020.11301