COVID-19 Live Forum Part III | Frequently Asked Questions

Is the research saying that these patients already had pre-existing Kawasaki Disease prior to COVID diagnosis, or were they healthy patients and then the diagnosis of COVID-19 caused Kawasaki Disease? 

• These are previously healthy children, presenting with symptoms similar to Kawasaki Disease that may meet full or partial criteria for Kawasaki disease. They are presenting with a mixed diagnosis of complete or incomplete Kawasaki Disease, Toxic Shock Syndrome, myocarditis, bacterial sepsis and Hemophagocytic lymphohistiocytosis (HLH)/macrophage activation syndrome (MAS).

 

For Kawasaki Treatment, there was mention of IVG and high dose aspirin. What dose of aspirin was used and in what age range?

• For patients meeting criteria for Kawasaki Disease or incomplete Kawasaki Disease, the recommended standard treatment is with IVIG 2g/ kg x 1 dose and Aspirin 30-50 mg/kg/day in 4 divided doses (max 4 g/day) with/without glucocorticoids. In the case report of a 6-month-old by Jones, et al., they used high-dose acetylsalicylic acid (20 mg/kg 4 times daily). However, some institutions are using lower doses of 3 to 5 mg/kg/day once daily. Limited data is available and optimal dose is not established. There are limited recommendations on age range dosing. It would be best to check with your own institution’s dosing protocol. 

References:

• McCrindle BW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017;135(17):e927. Epub 2017 Mar 29. 

• American Academy of Pediatrics. Kawasaki disease. In: Red Book: 2018 Report of the Committee on Infectious Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2018 p.490.

• Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr. 2020;10(6):537-540. doi:10.1542/hpeds.2020-0123

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Are there any comments on use of antibody testing for COVID? 

• A recent Cochrane review determined that many tests are reliable for symptomatic patients for up to one month after symptom onset. Other than that, there simply isn't enough data to say they are reliable or for how long.  The biggest data gap seems to be in asymptomatic populations.

References:

• Feels etval "Antibody tests for identification of current and past infection with SARS-CoV-2" Cochrane Library 2020; DOI: 10.1002/14651858. CD013652

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Can you please discuss when to hold DMARD, biologic or to maintain? When can a biologic help curtail the second week of CV 19 inflammation?

• For patients who are SARS-CoV-2 positive and able to stay at home (i.e. not sick enough for the hospital), the recommendations are like those for any respiratory illness (think influenza). Maintain oral DMARDs, hold biologics until symptoms have largely resolved.​

• The data on risks of cytokine storm vs. risks of immunosuppression with a biologic and/or glucocorticoid have not been conclusive. Many patients experience profound loss of T-cells with SARS-CoV-2 infection and further immunosuppressing them in order to prevent the inflammatory cascade from overwhelming the system is a delicate balancing act that should be handled on the inpatient side with input from multiple specialties.

 

Do you agree with limiting the usage of JAK inhibitors according to recommendations? Does the half-life of an immunosuppressant drug influence you on treating a RA patient with a JAK vs biologic?

• The jury is still out on JAK inhibitors. The risks of Janus kinase inhibition in terms of viral entry into cells are theoretical. Many compounds that are very similar to the JAKs used in rheumatology are being studied as potential treatments for COVID19, which is reassuring. In addition, it appears that this virus is not going away anytime soon. All medications carry risks. Therefore, carefully weighing the risks and benefits (like we always do) is the best anyone can do right now.

• Half-life of medications can be a factor in deciding which medication to use in some cases, but for COVID19 it is not really an issue. To put it metaphorically, by the time an individual is symptomatic the horses have already left the barn. 

 

Any comments on drive-by Prolia injections?

• I am all for it, however you would need to make sure the patient is able to properly check-in, have all information including insurance and identification verified since they obviously would not be registering at your front desk, and is technically on company property being that it is going to be billed as administered in office. I think anything we can do to minimize risk of COVID-19 for our patients, particularly older adults; while at the same time keeping them on-track with their Prolia is good. It is still important that we are keeping up with their labs, especially if we expect any abnormals. If labs have been stable and no change in diet or vitamins, then they can be checked just once yearly. 

 

Do to all the safety concerns emerging around HCQ even though they are clearly related to higher doses and in combination with other QTc prolonging agents, have you started screening higher risk (hx of CVD factors) with ECGs if they are on another QTc prolonging drug, like escitalopram? 

• I have not, and I have not heard of any of my colleagues doing so either. We have decades of experience with HCQ in rheumatology and major cardiovascular safety signals just have not been seen.

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Does taking TNF, IL-6, JAK agents prevent cytokine storms in RA patients infected with COVID? I read a study out of Italy showing less prevalence of pneumonia in RA patients on these agents.

• Please see above.

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