Older, Male Asthmatics at Greater COVID-19 Severity Risk

Liqin Wang, PhD

A pre-print article from a team of investigators at Brigham and Women’s Hospital and Harvard Medical School highlight the important of distinguishing asthma from chronic pulmonary conditions in interpreting patient risks due to coronavirus 2019 (COVID-19).

The findings, which show evidence for risk in asthma-coronavirus overlap, also highlight the continued burden clinicians face in interpreting symptoms between asthma and other chronic respiratory diseases.

The team, led by Liqin Wang, PhD, of the Division of General Internal Medicine and Primary Care, noted respiratory viral illnesses are often associated with asthma exacerbations in both children and adults. And indeed, research from COVID-affected regions of China have suggested chronic pulmonary disease is a risk factor for COVID-19 severity and mortality.

Currently, the US reports approximately 7-9% of hospitalized COVID-19 patients have chronic lung disease—with asthma being more prevalent than chronic obstructive pulmonary disease (COPD).

“Recent analyses of COVID-19 cohorts suggest that chronic respiratory disease may unexpectedly be less of a risk factor for COVID-19 infection and severity than non-respiratory diseases,” they wrote. “However, most studies to date do not distinguish asthma from COPD within chronic respiratory disease, limiting identification of asthma-specific risk factors.”

Wang and colleagues used data from March 3 to June 8 from the Massachusetts-based health system’s electronic health record (EHR) to establish their case series. Patients who were COVID-19 positive, aged ≥18 years old at diagnosis, with previously diagnosed asthma and a history of care in the health system were included in assessment.

The team sought associations of demographic and clinical characteristics with hospitalization and intensive care unit (ICU) admissions among asthmatic patients hospitalized for COVID-19, as well as those who died from it. Their assessment included both univariable and multivariable adjustments via age-stratified logistic regression.

Their eligible patient population included 1827 patients, with a median age of 54 years (IQR, 37-66), and two-thirds (67.4%) being female.

Most patients were triaged to outpatient care; 30.9% were hospitalized, and of that group, 41.8 (n = 236) were admitted to the ICU. Nearly all hospitalized patients were admitted to inpatient (99.3%) or ICU (97.9%) care within 2 weeks of COVID-19 diagnosis.

Among patients with asthma, mortality rate was 5.4% among both outpatient and hospitalized patients—with greater rates being reported among asthmatic patients who were hospitalized (15.6%) and/or admitted to the ICU (23.3%). More than 71% of patients who died did so within 14 days of their diagnosis.

Versus the outpatient group, hospitalized patients were observed to have greater baseline use of inhaled corticosteroid (ICS) and long acting-beta agonist (LABA) combination use, as well as more anti-cholinergic controller therapy. Fewer hospitalized patients had just a short-acting beta agonist (SABA) prescription in the past year (P <.001).

Wang and colleagues also observed significantly increased hospitalization risk associated with older age versus outpatient care (unadjusted OR, 1.46; 95% CI, 1.38-1.55; P <.001 for every 10 years). Males were also 75% more likely to be hospitalized versus outpatient care (aOR, 1.75, 95% CI, 1.36-2.24; P <.001), while Black (aOR, 1.65) and Asian patients (aOR, 3.19) were observed to be at greater hospitalization risk, as well.

Comorbid conditions associated with significantly greater hospitalization risk versus outpatient care included diabetes mellitus (aOR, 1.33); COPD (aOR, 1.92); or cardiovascular disease (aOR, 1.52). Investigators also observed significantly associations with obesity and chronic kidney disease; however, the findings were not robust.

“Several hospitalization risk factors for patients with asthma and COVID-19 reflect those identified in general populations of COVID-19 patients, including male sex, race, older age, and non-respiratory comorbidities,” investigators wrote. “Notably, male sex was a risk factor despite female predominance in COVID-19 testing and in positive diagnosis among asthma patients.”

Comorbid COPD was observed a strong risk factor for hospitalization—in fact, it was the only comorbidity that remained statistically significant after multiple comparison corrections. Asthma-specific variables were not predictive of neither ICU care nor mortality, and differences between risk for inpatient hospitalization and ICU admission were marked as a future avenue of assessment.

Investigators concluded that individuals with asthma-COPD overlap may be at particularly raised COVID-19 severity and mortality risk—though there is significant importance in distinguishing asthma from chronic pulmonary disease in COVID-positive patients to interpret individual risks.

“Further research examining the course of hospitalized patients is necessary to elucidate predictors of disease progression and clinical outcomes,” they wrote.

The pre-proof analysis, “Risk factors for hospitalization, intensive care and mortality among patients with asthma and COVID-19,” will be published in The Journal of Allergy and Clinical Immunology.