Fact Sheet 1

Risk factors for poor outcomes with COVID-19

Risk factors

Older age

To date, all available evidence suggests that illness severity increases with age.^1-7 In all studies, people who have died from COVID-19 or who have had more severe symptoms were older than people with less severe symptoms. In Europe, the rate of hospitalisation increased markedly with age over 60 years.² The proportion of people diagnosed with COVID-19 who died followed a similar pattern, with deaths higher in those aged over 60 years and markedly higher in those aged over 80 years.²

Male gender

Current evidence from Italy² and China⁷ indicates that a higher proportion of men than women die from COVID-19.

Current smoker

Evidence suggests that current smokers may be at an increased risk of severe illness if they contract COVID-19.^2,8

Multiple chronic conditions

To date, people with severe or fatal COVID-19 have had more chronic conditions than people who have experienced less severe COVID-19.^1,3,5,7,9 In Italy, 49% of people who died from COVID-19 had three or more chronic conditions.¹ In the USA, 78% of people admitted to intensive care with COVID-19 had at least one chronic condition, compared to only 27% of people with COVID-19 who were not admitted to hospital.⁹

Type of chronic condition

The current available evidence indicates that a higher percentage of people who have poor outcomes with COVID-19 have one or more of the following chronic conditions:

• hypertension^2-7
• chronic heart disease including heart failure, ischaemic heart disease^2-7,9
• diabetes^2-7,9,10
• chronic airways disease including COPD and asthma^3-7,9
• cerebrovascular disease^3,4,7,10
• chronic liver disease⁹
• chronic renal failure^3,5,7,9
• malignancy^2,3,6,7,11
• being immunocompromised or taking immune suppressing medicines.⁹

The prevalence of these chronic conditions in people with poor outcomes matches the prevalence for older age groups, so it is not yet clear whether people with these chronic conditions have worse outcomes due to the chronic conditions or due to their older age.

Living Guidelines: caring for people with COVID-19

An Australian national taskforce has developed evidence-based guidelines to support clinicians caring for people with COVID-19 in primary, acute and critical care settings.⁸ These guidelines are continually being updated and expanded as emerging data becomes available.⁸ To find out about disease severity and decision flowcharts for management of patients with COVID-19, go to: covid19evidence.net.au

For DVA patients with mild COVID-19 being managed in the community, and especially for those who are at heightened risk of poor outcomes if they contract COVID-19, advise them and their carer or family to look out for the development of new or worsening symptoms, especially breathing difficulties which may indicate developing pneumonia or hypoxaemia.⁸ If symptoms do worsen, this is most likely to occur in the second or third week of the illness.⁸

Consider transferring your patient to hospital if moderate to severe symptoms occur, including:

• signs and symptoms of pneumonia
• severe shortness of breath or difficulty breathing
• blue lips or face
• pain or pressure in the chest
• cold, clammy or pale and mottled skin
• new confusion or fainting
• becoming difficult to rouse
• little or no urine output
• coughing up blood.⁸

References for Fact Sheet 1

1. COVID-19 Surveillance Group. Characteristics of COVID-19 patients dying in Italy. Report based on available data on March 20th, 2020. Italy: Instituto Superiore di Sanita, EpiCentro, 2020.
2. European Centre for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – seventh update, 25 March 2020. Stockholm: ECDC, 2020. 2020: Available from: www.ecdc.europa.eu/sites/default/files/documents/RRA-seventh-update-Outbreak-of-coronavirus-disease-COVID-19.pdf [Accessed 2 April 2020].
3. Guan W, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020(e-pub ahead of print):DOI: 10.1056/NEJMoa2002032.
4. Wang D, Hu B, Hu C. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-9. doi:10.01/jama.2020.1585.
5. Zhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395:1054-62. doi:10.16/S0140-6736(20)30566-3.
6. Wu Z, McGoogan J. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China. Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020(e-pub ahead of print):doi:10.1001/jama.2020.648.
7. Chen T, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ.2020;363:doi:10.1136/bmj.m091.
8. National COVID-19 Clinical Evidence Taskforce. National clinical guidelines for COVID-19. Available at: covid19evidence.net.au [Accessed April 2020].
9. CDC COVID-19 Response Team. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. March 31 2020;Early Release / Vol 69:Available from: www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6913e2-H.pdf [Accessed April 2 2020].
10. Yang X, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respiratory Medicine. 2020(e pub ahead of print): doi:10.1016/S2213-600(20)30079-5.
11. Liang W, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncology. 2020;21(3):335-7.

 

   

Fact Sheet 2

What to tell patients about taking their routine medicines during COVID-19

Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)

There is currently no clinical evidence of harmful effects of ACE inhibitors or ARBs in the context of COVID-19, nor is there evidence to support stopping them because of COVID-19.^1,2 There are studies in animals that suggest these medicines may be protective against serious lung complications in patients with COVID-19, but to date there are no data in humans.¹

What to tell your patients taking an ACE inhibitor or an ARB

Patients routinely taking an ACE inhibitor or an ARB for the treatment of hypertension, heart failure or cardiovascular disease should continue to do so as prescribed, unless otherwise advised by you or their specialist.^1-3

Ibuprofen

To date, there is no clinical evidence to support a link between taking ibuprofen during COVID-19 and more severe outcomes if patients become infected.^4,5

What to tell your patients taking ibuprofen

Patients taking ibuprofen for short-term pain relief or for the management of a chronic condition should continue to do so as prescribed, unless otherwise advised by you or their specialist.^4,5 Patients should be encouraged to first talk with you before purchasing ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs) over the counter.⁴

Medicines with immunosuppressive properties, including disease modifying agents

If managing patients with suspected mild COVID-19, do not change the dose or stop long-term immunosuppressive medicines, including high-dose corticosteroids, chemotherapy, biologics, or disease-modifying antirheumatic drugs (DMARDs).⁶

For patients with asthma or chronic obstructive pulmonary disease (COPD) requiring systemic corticosteroids for a severe flare-up, ensure the flare-up is due to the pre-existing lung disease and not COVID-19.⁷

There are no medicines that have been approved by the Therapeutic Goods Administration (TGA) for the treatment of COVID-19; the TGA strongly discourages the use of hydroxychloroquine outside its current indications at this time.⁴ To limit the use of hydroxychloroquine to currently approved indications, restrictions have been placed on who can initiate therapy; from 24 March 2020 GPs can only prescribe repeats for hydroxychloroquine to patients in whom it was initiated by a specialist before this date.⁴

What to tell your patients taking medicines with immunosuppressive properties

Patients who are well with no fever or signs of infection and routinely take any of the following medicines, should continue to do so as prescribed, unless otherwise advised by you or their specialist:^5,6,8

• Steroids: prednisolone or prednisone^5,6,8
• DMARDs: methotrexate, hydroxychloroquine, leflunomide, sulfasalazine, azathioprine or mycophenolate^5,6,8
• Biologics (bDMARDs): adalimumab, etanercept, golimumab, abatacept, certolizumab, tocilizumab, infliximab, or targeted DMARDS (tsDMARDs), for example, baricitinib or tofacitinib^5,6,8

Patients taking these medicines who have signs of a fever, sore throat, shortness of breath or cough should call you at the first sign of symptoms and inform you of the medicines they take. Patients who are acutely unwell, such as having difficulty breathing, should call 000 for an ambulance, and inform paramedic staff of the medicines they take.^6,8

Patients routinely taking hydroxychloroquine in line with a currently approved indication, should continue to do so, unless otherwise advised by you or their specialist.⁴ The Federal Government is taking measures to ensure a continued supply of hydroxychloroquine is maintained.⁴

Patients with asthma or COPD should continue taking their medicines as prescribed, including inhaled or oral corticosteroids to manage severe flare-ups, have an adequate supply of medicines and an up-to-date written action plan.^7,9

Nebulisers should NOT be used to administer inhaled medicines during this time if possible; they generate aerosols that can spread infectious droplets for several meters.^6,7 To reduce the risk of spreading viral infections, all patients, including residents in aged care facilities, should use a pressurised metered-dose puffer and spacer with a tightly fitting face mask, if required, to administer inhaled medicines.^6,7

To ensure patients receive up-to-date, objective and trustworthy information, tell them to go to: www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert

Or to download the coronavirus Australia app on the App Store or Google Play at: www.health.gov.au/resources/apps-and-tools/coronavirus-australia-app

For patients experiencing distress and wanting to talk with someone, Open Arms is available 24/7 and can be contacted by phoning 1800 011 046 or at: www.openarms.gov.au/

References for Fact Sheet 2

1. Sparks M, et al. The coronavirus conundrum: ACE2 and hypertension edition. NephJC. Available at: www.nephjc.com/news/covidace2 [Accessed March 2020].
2. Heart Foundation. Heart medications and COVID-19: what health professionals need to know. Available at: www.heartfoundation.org.au [Accessed March 2020].
3. Zaman S, et al. Cardiovascular disease and COVID-19: Australian/New Zealand Consensus Statement. Med J Aust. 2020; preprint 3 April.
4. Australian Government, Department of Health. Therapeutic Goods Administration. Safety Information. Alert: New restrictions on prescribing hydroxychloroquine for COVID-19. Available at: www.tga.gov.au/alert/new-restrictions-prescribing-hydroxychloroquine-covid-19 [Accessed April 2020].
5. Australian Rheumatology Association. Advice for GPs and other Health Professionals caring for patients with Rheumatoid Arthritis, SLE and other autoimmune diseases in the COVID-19 crisis. Available at: https://rheumatology.org.au/gps/documents/AdviceforGPAHPcaringforpatientswithRheumataticDisease230320final_.pdf [Accessed April 2020].
6. National COVID-19 Clinical Evidence Taskforce. Version 1.0, 16 April 2020. Management of patients with suspected mild COVID-19. Available at: https://covid19evidence.net.au/wp-content/uploads/2020/04/NATIONAL-COVID-19_TASKFORCE_FLOW-CHART_4_MANAGEMENT-OF-SUSPECTED-MILD_v1.0_16.4.2020.pdf [Accessed April 2020].
7. National Asthma Council. Australian Asthma Handbook. Managing asthma during the COVID-19 (SARS-CoV-2) pandemic. Available at: http://asthmahandbook.org.au/clinical-issues/covid-19 [Accessed April 2020].
8. Australian Rheumatology Association. Important information for people with Rhuematoid and other Inflammatory Arthritis, SLE and other autoimmune diseases in the COVID-19 (Coronavirus) pandemic. Available at: https://arthritisaustralia.com.au/managing-arthritis/covid19/medicines-advice-regarding-covid-19/covid-19-and-advice-for-patients-on-immune-suppressing-medications/ [Accessed April 2020].
9. Lung Foundation Australia. Health Professionals. Available at: https://lungfoundation.com.au/patients-carers/lung-health/coronavirus-disease-covid-19/health-professionals-2/ [Accessed April 2020].

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