ARIA‐EAACI statement on asthma and COVID‐19 (June 2, 2020)

To the Editor, A novel strain of human coronaviruses, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), named by the International Committee on Taxonomy of Viruses (ICTV),1 has recently emerged and caused an infectious disease. This disease is referred to as the “coronavirus disease 2019” (COVID-19) by the World Health Organization (WHO).2 The US Centers for Disease Control and Prevention (CDC) have proposed that “People with moderate to severe asthma may be at higher risk of getting very sick from COVID-19. COVID-19 can affect your respiratory tract (nose, throat, lungs), cause an asthma attack and possibly lead to pneumonia and acute respiratory disease.” (May 24, 2020). (https://www.cdc.gov/coron aviru s/2019-ncov/need-extra -preca ution s/asthma.html) On the other hand, in the UK, NICE proposes rapid guidelines for severe asthma (https://www.guide lines.co.uk/covid -19-rapid -guide line-sever e-asthm a/455275.article). An ARIA-EAACI statement has been devised to make recommendations on asthma, and not necessarily on severe asthma, based on a consensus from its members. It is difficult in many studies to clearly assess the prevalence of asthma on COVID-19 since most patients are older adults and probably have multimorbidities. Most studies do not clarify whether asthmatic patients with COVID-19 have isolated asthma or asthma as a multimorbidity, particularly in the context of hypertension, obesity and diabetes. In particular, obesity is a significant risk factor for COVID-19 and its severity,3 and may be intertwined with asthma. In some studies, showing data mostly on critically ill patients, there does not appear to be an increased prevalence of asthma.4-7 In Wuhan, the prevalence of asthma in COVID-19 patients was 0.9%, markedly lower than that of the general adult population of this city.8 Differently, in New York, among 5,700 hospitalized patients with COVID-19, asthma prevalence was 9% and COPD 4.5%.9 In California, 7.4% of the 377 hospitalized patients had asthma or COPD.10 The US CDC reported that between March 1st and 30th 2020, among COVID-NET hospitals from 99 counties and 14 states (an open source neural network for COVID-19 infection), chronic lung disease (primarily asthma) was the second most prevalent comorbid condition for hospitalized patients aged 18-49 years with laboratory-confirmed COVID-19.11 Among the 17% of COVID-19positive patients with an underlying history of asthma, the incidence was at its highest in younger adults (27% in the 18to 49-yearold group). The UK experience on over 20, 133 hospitalized cases shows that 14% of admissions were patients with asthma.12 In the OpenSAFELY Collaborative Study (UK), an increased risk of severe COVID-19, including death, was found in patients with asthma, particularly related with a recent use of oral corticosteroid.13 A review with all identified studies up to 5 May 2020 is available.14 However, low socioeconomic status, obesity, non-white ethnicity, chronic respiratory disease and diabetes had stronger signals. Some anti-asthma medications, such as ciclesonide, might have a beneficial effect on COVID-19.15 Thus, whether patients with asthma are at a higher or lower risk of acquiring COVID-19 may depend on geography, age, other multimorbidities, different air quality,16 genetic predispositions, ethnicity, social behaviour, access to health care or other factors. Moreover, the current information is obtained mainly from hospitalization or intensive care unit data. Real-life data in a non-selected population of asthmatics are needed to better understand the links between asthma and SARS-Cov-2 in terms of both incidence and severity. Asthma does not seem to be a risk factor for severe COVID-19 but patients treated with oral corticosteroids may be at a higher risk of severe COVID-19.14 However, a large study is needed to fully appreciate the relationship between COVID-19 and severe asthma. According to the IPCRG (International Primary Care Respiratory Group), patients are still struggling to differentiate their symptoms between asthma flare-ups and COVID-19. They may therefore delay seeking care for asthma or COVID-19. Interestingly, clarity does not appear to have improved as the weeks have passed. People have recurrences or waves of repeated symptoms, and it is difficult to understand whether the symptoms are related to an asthma exacerbation or to COVID-19. According to the IPCRG, many clinicians tend to prescribe antibiotics to people who they believe are having asthma exacerbations “just to be safe.” They focus on the potential infection element of the trigger more than the asthma management itself. It would seem that COVID-19 might exacerbate this behaviour, not improve it. In areas where COVID-19 is prevalent, GPs are still very concerned about oral—and, to a certain degree, inhaled—corticosteroids, possibly because they use remote models of care. They are