As the seriousness of the COVID-19 pandemic became evident, allergist Dr. Kristin Sokol got busy. She wanted to make sure she could continue to treat patients with conditions such as food allergies, asthma and seasonal allergies – which are in full swing this time of year. Yet, she also needed to protect her staff and patients from potential exposure to the coronavirus.
The week of March 23, her D.C.-area practice started offering patients the option of a virtual visit using video chat instead of coming in to the office.
“We’re a small practice, and we had never had any experience with telemedicine,” says Sokol of Schreiber Allergy in Rockville, Maryland. “But it became clear last week that we needed to move as many patients as possible to telemedicine.”
With the spread of the COVID-19 pandemic, some allergists are closing their offices or limiting the services they offer. This relates to the shortages of personal protective gear and the need for social distancing to protect patients and staff alike. This means potential disruptions in care for adults and children with allergic conditions.
To find out what patients can expect from allergists in the coming weeks – and what aspects of allergy and asthma care may need to be adjusted because of the coronavirus pandemic – Allergic Living spoke with Sokol along with Dr. Brian Schroer, director of allergy and immunology at Akron Children’s Hospital in Ohio, and Dr. Christina Ciaccio, chief of allergy and immunology and pediatric pulmonology at the University of Chicago.
Allergist’s Office and Telehealth
In online medical forums, allergists say they are handling more issues over the phone, and trying quickly to establish virtual appointments via video conferencing. The ability to see patients face-to-face across a computer or smartphone screen has been especially helpful in calming frayed nerves. Sokol notes that some patients are worried they might have COVID-19 when they’re actually experiencing allergy symptoms.
Using a telehealth service called Doxy.me, Sokol sends patients a link before their appointment. They click the link to be entered into a virtual waiting room. The doctor’s visit begins when Sokol launches the video chat.
“Our office by the end of March would be booming, a lot of it because of springtime allergies,” she says. “COVID happened to occur at the same time a lot of our patients are sneezing, itching, have runny noses, coughs and scratchy throats. It’s really nice we can get online with them, see them, and calm their fears a little bit. We can look in our records and say, ‘You were in our office at the same time last year for the same symptoms. I think this is allergies and not COVID.’”
While the hope is that many allergists will offer video chat soon, some allergists who are technology-averse may not move as fast.
Because of the pandemic, allergists expect to have an easier time getting reimbursed by insurance for telemedicine visits with new patients than they would have had even in early March, 2020. So if your allergist is unavailable via video, you can try to reach another one who is offering virtual appointments.
If Sick, Don’t Come In
Allergists who still have limited in-office appointments are advising patients with fevers not to come into the office. In such a situation, contact your primary care doctor.
As a precaution, Sokol’s office is checking the temperature of any patient who comes in. They have removed magazines and toys from the waiting room and are cleaning all surfaces thoroughly, she says.
Be aware that some allergists’ offices are cancelling what are considered “nonessential” appointments. These may include: new allergy shots, skin-prick testing, visits for seasonal allergies, routine food allergy follow-up visits, new OIT appointments and food challenges.
This approach was endorsed by a panel of allergy and immunology experts, which issued a consensus statement noting that many patients could safely have much of their allergy and immunology care postponed or delayed, or handled through virtual care, while social distancing or quarantines are in place.
“With the exception of many primary immunodeficiency patients, patients on venom immunotherapy, and asthma patients of a certain severity, there is limited need for face-to-face visits under such conditions,” wrote the authors of the panel that was convened by the American Academy of Allergy, Asthma & Immunology (AAAAI), the American College of Allergy, Asthma & Immunology (ACAAI), the and the Canadian Society of Allergy and Clinical Immunology (CSACI).
Environmental Allergy Shots
“What I’m hearing is a lot of practices are spacing out the shots more,” Dr. Christina Ciaccio in Chicago.
Ciaccio’s office is giving allergy shots every two weeks instead of weekly during the build-up phase. Then every six weeks, instead of monthly, during maintenance. Some patients are opting to pause shots for the time being.
“If patients are already partially desensitized because they have already started immunotherapy, and we have to take an eight-week break, it would be relatively easy to get them back to where there were before,” she says.
Sokol’s office is spacing out shots, and also allowing patients to wait in their car during the monitoring period. Shot visits are now appointment-only, using online scheduling to limit the number of patients in the office.
What About Xolair and Dupixent shots?
Dr. Brian Schroer in Ohio says one group of patients who still need to come into the office are those getting omalizumab (Xolair) injections. Some allergists may be willing to meet the patient at their car to administer the biologic shot, or at least allow the patient to wait outside during the monitoring period. Xolair can potentially be given less frequently to minimize office visits, Schroer says.
Dupilumab (Dupixent) is administered by patients at home. If patients are new to the drug and not able to come into the office to learn how to do home injections, they can ask for a video chat with their allergist. Another option is to call 1-844-DUPIXENT to reach injection support services.
What if a Child’s on OIT?
Oral immunotherapy (OIT) is another treatment that may be impacted by COVID-19. If a child is about to start oral immunotherapy, parents may want to postpone it, Ciaccio says. Some allergists are not taking on new OIT patients at this time.
For patients who are already in OIT treatment, one option is to hold at the current dose, to avoid needing an office visit for updoses or food challenges. As well, this reduces the chance of needing to go to an emergency department in case of anaphylaxis.
“Those decisions are going to need to be made between the patient and the provider who is guiding them through OIT,” Ciaccio says. “Some practices are choosing to hold the dose. There is no hurry or rush to get to a maintenance dose. There is no harm in staying at a dose, even if it takes eight weeks before being able to updose.”
Sokol’s staff is continuing to come to the office to mix the powders and solutions they use for OIT for peanuts, tree nuts, sesame, milk and egg. A few families whose children have just started OIT have decided to hold off continuing, for now. For others who are farther along in the process, she is providing two weeks of additional doses on top of the two weeks of doses they normally receive.
Putting Off Food Challenges
While most OIT patients can hold off on updoses or food challenges, participants in research studies may need to continue on schedule, because delaying the interval could throw off the results.
Likewise, if a child’s health is compromised because of a lack of nutrients, oral food challenges may still be necessary. “Unless there is a critical acute nutritional need for introduction of a key nutrient, it is likely that all food challenges would be deferred,” the expert panel wrote.
OIT & Coronavirus Risk
There is nothing to indicate that children are more vulnerable to the COVID-19 virus during OIT. “While on OIT your immune system will fight viruses just as well,” says Schroer.
However, if your child does develop symptoms of the coronavirus, particularly fever, parents should follow their allergist’s guidelines for dealing with viral illnesses such as flu. For many patients, that is typically lowering the dose or possibly skipping dosing. If illness occurs, be sure to contact your doctor.
From research, “it is clear that any virus can increase the possibility of having anaphylaxis to previously tolerated doses of OIT,” Schroer says. “Therefore you should use any mitigation strategy for infections that was previously discussed with your allergist.”