Expert Opinion from our Chair, Mohamad Mohty, on COVID-19 and GvHD

This transcript is provided from a call held between the GvHD/Multiple Myeloma Hub and Professor (Prof.) Mohamad Mohty. We would like to thank Prof. Mohty for taking the time to speak to us and providing these recommendations for the management of coronavirus disease (COVID-19) during the SARS-CoV-2 pandemic.

GvHD Hub: What is your advice for clinicians treating patients with hematological malignancies during the COVID-19 pandemic, and for patients?

Prof. Mohty: “Patients with hematologic malignancies who have received multiple chemotherapies and/or stem cell transplantation, whether autologous or allogeneic, are patients with a very high risk when it comes to the COVID-19 infection. We know very well that these patients are highly immunosuppressed and that can be due to several reasons, including the immune suppression induced by the different treatments they receive, or they are receiving. We also know that the disease by itself can create a status of immune suppression, and obviously when it comes to allogeneic stem cell transplantation, they are actively receiving immunosuppressive therapy. So clearly based on the current information we have and based on the experience in China, for instance, if you look into the outcome of cancer patients in general when they got the COVID-19 infection, it is clear that the risk of morbidity and severe complications is significantly higher than the normal population. Also, you should not forget that the hematology patients usually have a relatively advanced age, and we also know from studies, that age by itself is a risk factor for negative outcome when it comes to COVID-19.

So, with this in mind, I think it’s crucial to try to protect these patients from the COVID-19 infection. But of course, at the same time, you would like to be careful not to compromise the history or the specific treatment of the hematologic disease.

I think the rule that applies to the general population when it comes to confinement, when it comes to hand washing, when it comes to social distancing, when it comes to using masks, especially when outside or in the healthcare facility, is absolutely of crucial importance in the hematological patients.

In general, a patient could absolutely minimize the number of visits to the hospital, because you would want to avoid any circulation of the virus. The virus doesn’t have a virus cell, the virus uses the human patient as a vehicle, so you definitely need to minimize the circulation of the virus. The patients should discuss with their physicians about where there is a crucial or medical need for a given visit. Whenever possible, treatment should be administered at home, or the duration or the visit to the hospital should be minimalistic, but also one would like to mostly use telemedicine.

When it comes to therapies in general, the physicians should carefully look to each patient individually. We know already that some treatments can be postponed, or delayed, without impacting the patient’s outcome. Of special importance is the use of corticosteroids, because corticosteroids in the case of the COVID-19 infection are correlated with a bad outcome. So, whenever possible, you should try with these patients to decrease or even discontinue the use of corticosteroids. In particular, I’m thinking about the myeloma patients where regimens tend to include dexamethasone, but also I’m thinking about the GvHD patients, those patients who have been/are being treated for acute or chronic GvHD after allogeneic stem cell transplantation, so all efforts should be used. This should be a significant decrease in those that are very at risk, and may extend as far as suggesting other immunosuppressive agents. The global general view compared to the general population, is to increase vigilance in these patients and use therapy adjustments whenever possible. At the end of the day, one would like to clearly avoid the hematology patients developing the COVID-19 infection since the outcome would be very dismal, especially given that we do not have, today, any effective therapy or any effective prophylaxis.

So, I think the best prophylaxis and therapy is to limit any movement and to be confined at home along with all the protective measures.”

GvHD Hub: Do you have any specific advice with regards to the allocation of scarce intensive care unit (ICU) resources?

Prof. Mohty: “If they [the hematology patients] are already in intensive care, the outcome is really very bad. Obviously when planning therapy, and when planning the course of a given therapy, in hematological patients during this COVID-19 outbreak, you need to pay attention to the fact that the number of ICU beds can be very limited. Therefore, we need to be careful and would try to avoid those intensive treatments where there could be a big challenge to find an ICU bed. At some point—and this is outside, I would say, of the hematologists—the number of ICU beds is limited and our need from ICUs is going to, or would need to, make up the shortage or share allocations of the medical resources and ICU resources.

The good news, as of now, at least when it comes to European countries, is that I haven’t heard about such very stringent or strict allocation where hematology patients were excluded [from ICU care]. For the time being, thanks to a close collaboration between the hematologists, between the ICU physicians, between the whole organization around the COVID-19 outbreak, we managed to actually have a sort of a, I would say, permanent communication to be able to avoid being faced with choices that we would like to avoid.“