March 18, 2020
Hello Wise Patients!
As we are sure you all are aware, the situation around COVID-19 testing is rapidly evolving. We have paid special attention to the current testing recommendations, as well as the shortages of supplies associated with testing.
Prior to the establishment of progressively stricter self-isolation recommendations (ie. no gatherings >10 people) by public health officials, we began to operate under the idea that expanding testing could help us counsel which patients needed to self-segregate from the public sphere.
WPIM COVID-19 TESTING CAPACITY AND CONSIDERATIONS
Two major updates have shifted the ways in which we consider offering testing for patients who are concerned for acute infection:
- The broader closure of social and public spaces has meant that for many of us, symptomatic or not, the best plan is self-isolation at home (with limited exception for essential travel during which social distancing behaviors are maintained). For those patients who have a concern for symptoms of COVID-19, management of their illness will likely be the same for anyone who does not belong to, or work with, members of a high-risk category (eg. age 60 years or over, those with chronic illness, immunosuppressed or pregnant persons).
As of 3/15/20, guidelines that UW Medicine published with insight from the WA Department of Health indicate testing for the following groups (who have symptoms of COVID-19):
- Patients hospitalized with severe lower respiratory illness
- Healthcare workers
- Patients in public safety occupations (eg. law enforcement, fire fighters, EMS)
- Patients involved in a local illness cluster in a facility/institution (ie. healthcare setting, school, corrections, homeless/shelters, nursing home/adult care facility, institution/congregate setting)
Younger, otherwise healthy patients with relevant, mild illness are being counseled to forego testing. Rather, current recommendations endorse continued isolation at home (and from those within the home as much as possible) until at least 72hrs post-resolution of all symptoms. Testing is not recommended in those who are asymptomatic.
- The expansion of testing capabilities has been far more limited than what we hoped for as of writing last week’s newsletter. Early-on during the outbreak there was a lag in academic and commercial labs receiving the authorization to start testing samples with both supplied and proprietary testing kits. While more organizations have been able to bring their testing capacity online, we are beginning to see shortages in the available supplies for those very tests (reagents, kit materials, etc).
For reference, our facility currently has on site #33 UTM Viral specimen tubes with which to submit patient specimens for SARS-CoV-2 screening.
Alongside this, we are noticing that with the tests we have ordered thus far there has begun to be a backlog for results (what was estimated as 3-4 days for result turn-around, is becoming 5+ days).
Given the above, we are carefully weighing the decision to test each patient as they report symptoms. Do not hesitate to reach out if you are concerned you may be experiencing symptoms consistent with COVID-19. Our team will work with you to determine the best appropriate course of action based on the individual parameters of your health and your engagement with the public.
MEDICATION SPOTLIGHT: If you take an NSAID, ACE Inhibitor or ARB Medication, please read this
NSAIDs include ibuprofen, naproxen, diclofenac, meloxicam etc.
ACE inhibitors end in ‘pril’ and include lisinopril, enalapril, benazepril, etc
ARBs end in ‘artan’ and include losartan, olmesartan, valsartan, etc
As of yesterday evening the World Health Organization recommends avoiding NSAID medications for COVID-19 symptoms. This is based on the concern that NSAIDs stimulate an increase in the ACE2 receptors that the SARS-CoV-2 (the virus that causes COVID-19) binds to on cells in the lung, heart, and blood vessels. Some scientists have hypothesized that drugs that stimulate more ACE2 receptors might increase the risk of developing severe or fatal COVID-19. We agree with this precautionary recommendation to avoid NSAIDs for musculoskeletal pain and try tylenol (acetaminophen) first, while we wait for more evidence. Some of you take NSAIDs chronically for unique conditions, rather than as-needed for musculoskeletal pain. You should reach out to us so we can help personalize our advice to you.
On ACE inhibitors and ARBs:
Here is what we want to know:
- Is there a link between COVID-19 infection and hypertension (elevated blood pressure) in humans?
- Are patients on ACE inhibitors at increased/decreased risk of infection or severity of disease?
- Are patients on ARBs at increased/decreased risk of infection or severity of disease?
- Does modulation of these drugs (starting, stopping, or continuing) lead to better or worse outcomes in COVID-19?
This topic is complex, with more disagreement among experts. The backstory overlaps with the NSAID discussion above. Observations have been made that non-survivors of COVID-19 were more likely to have hypertension (HTN), diabetes (DM), coronary artery disease (excess plaque build-up in heart arteries), or cerebrovascular disease (excess plaque build-up in brain arteries). These conditions are often treated with angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type-1 receptor blockers (ARBs). We use these medications a lot because they work in preventing diseases like heart attacks, strokes, and kidney failure; and they have exceptionally few side-effects. SARS-CoV-2 binds to target cells ACE2 receptors. ACE2 receptors are found predominantly in the lungs, heart, blood vessels, and intestines (kidneys and testicles too). Some scientists have hypothesized that drugs that stimulate more ACE2 receptors might increase the risk of developing severe or fatal COVID-19, as would other variations in ACE2 receptors among different people.
Other scientists have argued that ARBs may be protective against severe COVID-19 by way of preventing complications in the heart, since some severe cases are dying from cardiac complications in excess of what would be expected based on their degree of lung injury from the infection.
Another concern is that suddenly stopping ACE inhibitors or ARBs in some people can put them at risk for heart failure and/or blood pressure crisis requiring hospitalization and thus more exposure to SARS-CoV-2 than they would have had sheltering at home on their medication.
We have been checking this great link daily, which updates expert group recommendations on this important ACE inhibitor / ARB topic:
Every expert group currently recommends against stopping your ACE inhibitor or ARB medication on the basis of COVID-19. We agree with this recommendation though we are available to discuss the topic with you and will continue to follow available science as it unfolds.
GOING THE DISTANCE WITH SOCIAL DISTANCING:
Our understanding of COVID-19 and its local impact continues to evolve daily. We recognize this makes it difficult to discern what recommendations are relevant and reasonable amidst many information sources. However, Wise Patient wants to emphasize one step we all can and should take seriously — social distancing.
Social distancing is paramount to helping slow the spread of COVID-19 and avoid overloading our healthcare providers, resources, and system. We understand it can be an isolating and lonely process, so please review our segment on creative things you can do to stay connected during this time.
Practicing social distancing means avoiding unnecessary contact with other groups and individuals. This helps minimize opportunities for the virus to spread. Decreasing exposure opportunities is critical because many patients who contract COVD-19 will have mild symptoms. A recent study published in the Annals of Internal Medicine showed the median incubation period for COVID-19 was estimated to be 5.1 days and 97.5% of those who develop symptoms will do so within 11.5 days of infection. Therefore it’s critical to shelter in place and practice social distancing to avoid inadvertently spreading the disease before you present with symptoms. Additionally, some patients may contract the virus and remain asymptomatic. Asymptomatic patients can still be vectors for spreading the virus to others, including vulnerable individuals.
Since social distancing is a preventative measure, the sign of success is the absence of disease which can be harder to conceptualize. The Washington Post created a very enlightening visualization of how a disease like COVID-19 would progress with varying levels of social distancing. We hope you might review the simulations to see how important this measure will be for containing COVID-19.
What we can do:
While we are encouraging you to “shelter in place” and follow social distancing measures, we want you to know that we are here for you. Now is the time to lean in to our capacity to practice distance medicine through messaging, phone appointments and video appointments. Our goal is to be in touch with each of you and address your questions, concerns and medical issues without interruption. When we can do that through distance care, we will. If there are issues that need to be addressed in a timely manner with hands on, we are here and can see you in the clinic. We still have on-line scheduling turned off, but you can call the clinic or message us through Spruce and we can make a plan together.
Given all of the focus on what NOT to do, we want to also focus on what you can do. Many of you have had questions about what they can do to ensure they are staying as healthy as possible and also what they can do to help the community.
What you can do to keep yourself healthy:
- Get outside – especially with the weather being nice, getting outside for a walk either alone or with a family member, while staying 6 feet away from other individuals is a great way to continue to get exercise and fresh air. It’s good for our physical and psychological health.
- Continue to exercise at home. Gyms and yoga have closed leaving many of us without the routine and social connection to keep us in our exercise routines. There are options to join classes from home through many different studios. Some include: kpffitness.punchpass.com – live streaming fitness and yoga classes for free/donation as long as social distancing measures are in place, 8limbsyoga.com is also currently offering free live stream classes.
- Stay connected socially through technology. We humans are social animals and social distancing goes against all of our instincts. It is so simple, but it is hard. Use technology to stay in touch with friends and loved ones through audio and video chatting, but minimize the amount of time that you spend on social media. The relationship between increased time on social media and anxiety is probably linear.
- Getting groceries – buying groceries may be the one reason most people need to leave their homes. Here are some tips for making that as low risk as possible:
- If you have symptoms like a cough, fever or shortness of breath, ask a friend or neighbor for help in getting your groceries or use a grocery delivery service.
If you are a patient at high risk of complications (age >60, pregnant, immunocompromised, chronic lung or kidney disease), there are several grocery stores that are creating periods of time when access will be restricted to other people at high risk. (Target, Uwajimaya, Albertsons, Safeway are among stores currently offering this). This will eliminate exposure to other people there, but will not remove the necessity of careful handwashing, avoiding touching your face, etc. Do self check out when possible to minimize the number of hands touching your groceries.
What you can do to help:
- Donate blood. Given the social distancing measures, blood drives that usually occur to maintain our regions supply of blood have been cancelled. Our current blood stock is low. Bloodworks NW is asking for blood donations. If you are healthy and meet their criteria, you could consider donating blood. https://www.bloodworksnw.org/ to schedule an appointment.
- Donate funds! In times like this when individuals are hoarding food from those who need it, food security becomes more important for those who are at risk. Northwest Harvest is committed to promoting healthy eating while reducing hunger. At this time, people are in need of food more than ever, so consider donating to them today to help them purchase food for communities that need it.
- Send letters/cards to residents of nursing homes. Do you have kids at home from school closures? Consider having them create artwork and write letters to send to nursing homes and retirement communities where residents are isolated.
Sources for this publication & resources for more information:
- Washington State Dept. of Health has established a call center to address questions from the public: 1-800-525-0127 and press #.
- King County Public Health:
- Center for Disease Control: https://www.cdc.gov/coronavirus/2019-ncov/index.html
- Washington Post
- Annals of Internal Medicine
- UW Medicine: Video w/ Dr. Santiago Neme an infectious disease specialist and Medical Director at UWMC
If you have any questions, please contact our office at: firstname.lastname@example.org
“Ask your doctor if staying home is right for you!” (Spoiler alert, it is.)