Sharp HealthCare COVID-19 Treatment Guidelines (V7)

Intro The intent of this guideline was to summarize existing clinical framework for clinical management of adult hospitalized patients COVID-19 (Covid) at Sharp HealthCare facilities. Now more than 18 months into the pandemic, and will the availability of excellent and regularly updated guidelines, we refer providers to NIH COVID Treatment Guidelines as our primary treatment guideline for care at Sharp hospitals and facilities.

For any provider regularly caring for patients with Covid or MIS, please sign up through the NIH website to receive guideline updates via email.

Sharp HealthCare Emergency Use Authorization (EUA) Workgroup To provide safe, effective, and high-value care to our patients with Covid, Sharp HealthCare convened an emergency use authorization (EUA) pharmacy and therapeutics Covid workgroup which reports to HID. This group is composed of physician leaders including all site CMOs, pulmonology, hospitalists, emergency medicine, OB, infectious disease, rheumatology, occupational health, as well as our system pharmacy and ASP experts. The workgroup regularly reviews existing literature on treatments for Covid, with focus on drugs that have received EUA approval, as well as the off-label use of some select agents.

This workgroup may occasionally supplement this document or provide SBAR updates to the medical and pharmacy staff based on the evolving nature of the pandemic, available therapies, drug shortages, and contingency planning needs—such as availability and preference on the use of DMARDs that may not be covered within the scope of NIH Guidelines.

If new and highly promising therapies become available, or existing ones have a serious safety signal, the EUA workgroup may in some instances provide guidelines and workflow support ahead of updated NIH practice recommendations.

We also emphasize NIH’s position that “whenever possible, the Panel recommends that promising, unapproved, or unlicensed treatments for COVID-19 be studied in well- designed, controlled clinical trials. This recommendation also applies to drugs that have been approved or licensed for indications other than the treatment of COVID-19. The Panel recognizes the critical importance of clinical research in generating evidence to address unanswered questions regarding the safety and efficacy of potential treatments for COVID- 19.”

Select topics that are out of scope or not covered by NIH guidelines are also elaborated upon below. Diagnostic Testing Please refer to NIH guidelines about viral-specific testing for SARS-CoV-2 infection

- 1 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

Sharp HealthCare remains unique among healthcare organizations, reflexively sending nearly 100% of positive PCR cases for viral whole genome sequencing from emergency department and hospitalized patients. De-identified viral genomic profile of our patients are included and regularly updated at Outbreak.info, SEARCH Alliance, and Nextstrain.org.

Covid Treatment Summary As of August 2021 we refer providers to the NIH COVID-19 Treatment Guidelines for additional guidance on care for patients with Covid. Information is available for the following and additional topics on the NIH website:  Non-hospitalized patients general management and therapeutic management  Hospitalized adults: therapeutic management  Critical care

- 2 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

Multisystem Inflammatory Syndrome Beyond the well-described COVID-19 syndrome, large case series from the US1,2 and Europe3 also indicate SARS-CoV-2 infection triggers a Multisystem Inflammatory Syndrome (MIS) reminiscent of Kawasaki and toxic shock syndromes in a small percent of infected persons.

Early symptoms of this syndrome in pediatric patients (MIS-C) are notable for the absence of significant respiratory symptoms; children instead may present with fever, abdominal symptoms including diarrhea, rash, limb swelling1,4. In addition to elevated inflammatory markers, myocarditis and other cardiovascular changes may be seen5. At present, three tentative phenotypes appear to present in pediatric cohorts: fever and elevated inflammatory markers without mucocutaneous inflammation or end-organ damage; shock with myocarditis and left ventricular dysfunction; and typical + atypical Kawasaki syndrome, occasionally progressing to a shock syndrome2,6.

Since June 2020, several case reports have also described a similar syndrome in adults, now called Multisystem Inflammatory Syndrome in Adults (MIS-A). In contrast to Covid, the patients with MIS-A had minimal respiratory symptoms, hypoxemia, or radiographic abnormalities at the time of presentation to care—though half of cases did report respiratory symptoms before onset of MIS-A. Case series indicate a wide range of susceptible ages – 20 to 50 years-old – though generally MIS-A appears to be more common in younger to middle age adults. As with MIS-C, ethnic and racial minorities appear to be at much higher risk for this condition.

Similar to the pediatric presentation, MIS-A cases predominantly reported non-respiratory complaints at the time of initial assessment: constitutional (fever), cardiovascular symptoms (chest pain, palpitations), gastrointestinal (diarrhea, abdominal pain), and dermatologic (rash, mucositis) symptoms were all common features. As with COVID, these MIS-A cases also had markedly elevated CRP, ferritin and d-dimer levels, and some demonstrated lymphopenia. Cardiac abnormalities including elevated troponin, abnormal ECG, and abnormal echocardiogram findings (LV and/or RV dysfunction) were common. Testing for SARS-CoV-2 PCR has been negative in about half of these cases, and serology for SARS-CoV-2 infection if sometimes but not always positive. Many of these patients developed serious or critical illness, with treatment regimens akin to MIS-A (IVIG, corticosteroids)6–8.

Summary of CDC case definitions of Multisystem Inflammatory Syndrome in Adults8 1. Severe illness requiring hospitalization in a person aged ≥21 years; with 2. Positive test result for current or previous SARS-CoV-2 infection (nucleic acid, antigen, or antibody) during admission or in the previous 12 weeks; and 3. Severe dysfunction of one or more extrapulmonary organ systems (e.g., hypotension or shock, cardiac dysfunction, arterial or venous thrombosis or thromboembolism, or acute liver injury; and 4. Laboratory evidence of severe inflammation (e.g., elevated CRP, ferritin, D-dimer, or interleukin-6); and

- 3 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

5. Absence of severe respiratory illness (to exclude patients in which inflammation and organ dysfunction might be attributable simply to tissue hypoxia).

*Patients with mild respiratory symptoms who met these criteria were included. Patients were excluded if alternative diagnoses such as bacterial sepsis were identified.

NOTES: Some individuals may fulfill full or partial criteria for Kawasaki disease but should be reported if they meet the case definition for MIS.

PRACTICE ADVICE: 1. Providers should consider MIS in adults with compatible signs or symptoms 2. Both SARS-CoV-2 PCR and serology testing should be ordered on any person suspected of MIS 3. Additional lab work for suspected cases of MIS should include: CBC with differential, BMP, LFT, ferritin, D-dimer, CRP, ESR, LDH, high-sensitivty troponin, BNP, along with additional labs as clinically indicated 4. Provider should order and ECG and transthoracic echocardiogram in any patient suspect of MIS 5. Providers should initial continuous cardiac telemetry in any patient suspect of MIS 6. Providers should consider following additional diagnostic and treatment guidelines detailed in the American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS–CoV‐2 and Hyperinflammation in Pediatric COVID‐199, with dosing adjustments in consultation with pharmacy. Additional guidance is available at UpToDate: Multisystem inflammatory syndrome in children (MIS-C) management and outcome 7. Providers should consider contacting the Rady Children’s Hospital Kawasaki group for research and clinical care recommendations. (Dr. Lichtenstein is available to faciltiate rapid contact with the RHCSD KD group if needed.)

- 4 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

Endocrinologic Complications

Inpatient Glycemic Management in Diabetic Patients with COVID The serious consequences of diabetes mellitus (DM) with COVID are now well recognized. Over one third of Sharp hospitalized COVID patients have diabetes. Admission hyperglycemia (with or without diabetes), known diabetes, in hospital blood glucose (BG) > 180 mg/dl and hypoglycemia with COVID are all associated with increased complications and mortality10–13. In addition, new onset diabetes associated with COVID often presents with severe metabolic disturbances such as diabetic ketoacidosis and hyperosmolarity, frequently requiring very high doses of insulin. COVID hyperglycemia is the result of the virus causing decreased insulin production and increased insulin resistance14–17. Maintaining BG < 180 mg/dl during hospitalization without hypoglycemia is associated with lower mortality and complications14,15,18–21.

While reports show that controlling hyperglycemia is associated with benefit, the management is very challenging. Not only is glycemia compounded by frequent treatment with corticosteroids and alteration in nutrition, the logistics dictated by COVID isolation creates barriers to any treatment requiring frequent monitoring such as insulin treatment.

The cornerstone of diabetes management with COVID is early recognition of hyperglycemia and early treatment. POC (point of care) BG should be started immediately if admission or any fasting BG > 140 mg/dl, with or without known diabetes. Treatment should be started if two fasting BGs are > 140 mg/dl or any BG > 180 mg/dl. The current medication of choice is insulin. The possible use of non-insulin hypoglycemia agents is under investigation especially DPP4i (dipeptidyl peptidase-4 inhibitors, e.g., sitagliptin) and metformin22–26.

The key to insulin management is to adjust the TDD (total daily dose), use the "enhanced phase" in the insulin power plans early, provide ≥ 60% of the TDD as basal and adjust meal doses for steroids. At the same time, keep POC BGs to 4/day for eating and 4-6/day for NPO patients. The POC BGs and insulin doses should be bundled with otherwise needed RN patient visits. In the ICU insulin infusion (CII) should be used to stabilize hyperglycemia with 2-hour monitoring and the COVID target of 140-180 mg/dl as delineated in the CII power plan.

Current subcutaneous power plans provide the framework to order insulin COVID patients just as for any hospitalized patient with diabetes or hyperglycemia. The guidelines attached to the subcutaneous power plans (accessed with the evidence-based link) are applicable to COVID patients. A summary approach is outlined the practice advice table detailed below.

The enhanced NPO or eating phase should be used for most well-nourished patients, especially if receiving corticosteroids. Insulin should be escalated daily if BGs are > 180 mg/dl and doses revised if any BG is < 100 mg/dl. Major contributors to uncontrolled hyperglycemia should be corrected such as excessive calories in diets, or enteral nutrition, or glucose in IV fluids and piggybacks. If serum HCO3 ≤15 moll/L, acetone and/or β-hydroxybutyrate should be checked.

- 5 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

PRACTICE ADVICE:

Table 1. Management recommendations for hyperglycemic or diabetic COVID patient. Start POC BG and Insulin POC BG at least 2- 3x /day Admit BG > 140 mg/dl Any fasting BG > 140 mg/dl Start insulin All Type 1 DM patients All known Type 2 DM patients After any BG > 180 mg/dl, with or without DM Starting Insulin TDD – total daily dose Simple estimate – 0.6 units /kg Obese 0.6 to 2 units/kg Average patient 0.6 – 0.9 units/kg Frail, malnourished, elderly 0.4 – 0.6 units /kg Basal - Glargine 60% of TDD (simple weight based estimate - 0.3 to 0.4 units /kg; single dose at 2200 Correction Order for all patients receiving insulin; check the box for 2200 coverage for patients on an insulin eating phase Meal Chose the Average or Resistant (high ) phases of the power plan Chose the Sensitive phase for frail, malnourished, elderly Steroids increase the meal dose insulin needs much more than basal needs Daily review and adjustment Escalate basal on “10/20/30 rule” Fasting BG 180- 200 ↑ basal by 10% Fasting BG 201-300 ↑ basal by 20% Fasting BG > 300 ↑ basal by 30%

Adjust meal dose ↑ 1-3 units if BG following the meal is > 140 ↓ 1-3 units if BG following the meal is < 100 Deescalate Rapidly if corticosteroid are stopped or when decreased As patient’s condition improves ICU For uncontrolled hyperglycemia, insulin infusion with the COVID modifications which are now part of the power plan DKA or HHS ICU with DM Crisis Power Plan Special Considerations HCO3 < 18 mmol/L Check acetone

DPP-4 inhibitors Dipeptidyl peptidase 4 (DPP-4) inhibitors, e.g. sitagliptin, saxagliptin, linagliptin, are a class of oral diabetes drugs that inhibit the DPP-4 enzyme. It is postulated that DPP-4 may interact with the S1 domain of the viral spike glycoprotein of SARS-CoV-227. Current guidelines do not endorse or reference the use of DPP-4 inhibitors for the treatment of patients with COVID. Observational, retrospective studies reporting on the relationship between DPP-4 inhibitor

- 6 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7) therapy and patient outcomes among those with diabetes and COVID have provided heterogeneous results, preventing definite conclusions of their impact27.

A multicenter, case-control, retrospective, observational study was conducted in patients with type 2 diabetes and COVID in Italy21. 169 patients received sitagliptin in addition to standard of care (SC or IV insulin) and 169 patients received standard of care alone. Sitagliptin was associated with lower mortality, clinical score reduction, hospital discharge, and decreased need for intensive care and mechanical ventilation. However, these results are tempered by significant limitations including selection bias, differences in patient characteristics, incomplete data collection in 30%-40% of patients, and lack of reporting on concomitant therapies, including corticosteroids (remdesivir not standard of care during trial period). Glycemic control, which has been associated with improved outcomes in diabetic patients with COVID, was significantly better in the sitagliptin group. Given the limitations of available literature, RCTs are needed to confirm these results. Although hypoglycemia is not common with DPP-4 inhibitors, the risk is significantly increased when administered concomitantly with insulin or insulin secretagogues28.

At present, the use of DPP-4 inhibitors are not routinely used for glycemic control for hospitalized patients and constitute a non-formulary class of medications at most entities.

PRACTICE ADVICE:  The use of DPP-4 inhibitors specifically for treatment of patients with COVID is not recommended outside of a clinical trial  DPP-4 inhibitors may be continued during admission for type 2 DM patients who were taking the drug at home prior to hospitalization o SMV: orderable as formulary medication o SGH, SCO, SCV, SMB: non-formulary; approved for patient’s own medication o SMH: non-formulary, available under restrictions

- 7 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

Discontinuation of Isolation Share HealthCare Infection Prevention affirms the updated CDC guidelines for discontinuation of isolation precautions in COVID patients. Please refer to SHIP for reference and further guidance on this important topic. Providers are encouraged to review individual cases with SHIP for case-specific guidance.

Please note that entity-level IP are the ultimate arbiters of whether to continue or discontinue transmission-based precautions in patients with COVID. A summary of their assessment and determinations may be viewed in Cerner under “Interdisciplinary Documentation”, “Infection Prevention Note”. General Discharge Considerations Prolonged hospitalizations, often complicated by critical illness and mechanical ventilation, remain a major challenge for patients hospitalized with COVID. In anticipation of discharge, providers should work closely with case managers to identify patient needs and barriers to discharge.

PRACTICE ADVICE:  Patients may be ready for discharge when clinically stabilized and recovering. This typically means that the patient is no longer febrile or hypoxemic, and any residual dyspnea or other symptoms do not preclude them from engaging in activities of daily living. Consistent with the clinical picture, other lab testing should also improve and/or normalize prior to discharge.  All patients should be evaluated for resting and exertional hypoxemia prior to discharge.  Consider PT and OT evaluation in all patients with COVID who required mechanical ventilation and/or prolonged hospitalization, are hemodynamically stable and able to follow commands.  Transmission-based precautions may be discontinued at discharge using a time- or symptom-based strategy as outlined by CDC29 and SHIP30. Please refer to SHIP for additional details.  For patients who do not meet symptom- or time-based criteria to discontinue transmission-precautions, isolation should be maintained at home or another suitable discharge venue identified until the patient can meet criteria to discontinue transmission- precautions29

- 8 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

References

1. New York City Health. 2020 Health Alert #13: Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19. Accessed May 13, 2020. https://picsociety.uk/wp- 2. Whittaker E, Bamford A, Kenny J, et al. Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS- CoV-2. JAMA. Published online June 8, 2020. doi:10.1001/jama.2020.10369 3. Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet. 2020;0(0). doi:10.1016/S0140-6736(20)31103-X 4. Cai X, Ma Y, Li S, Chen Y, Rong Z, Li W. Clinical Characteristics of 5 COVID-19 Cases With Non-respiratory Symptoms as the First Manifestation in Children. Front Pediatr. 2020;8:258. doi:10.3389/fped.2020.00258 5. Center for Disease Control and Prevention (CDC). HAN Archive - 00432 | Health Alert Network (HAN). Accessed May 14, 2020. https://emergency.cdc.gov/han/2020/han00432.asp 6. Feldstein LR, Rose EB, Horwitz SM, et al. Multisystem Inflammatory Syndrome in U.S. Children and Adolescents. N Engl J Med. Published online June 29, 2020:NEJMoa2021680. doi:10.1056/NEJMoa2021680 7. Godfred-Cato S, Bryant B, Leung J, et al. COVID-19–Associated Multisystem Inflammatory Syndrome in Children — United States, March–July 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1074-1080. doi:10.15585/mmwr.mm6932e2 8. Morris SB, Schwartz NG, Patel P, et al. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep. 2020;69(40). doi:10.15585/mmwr.mm6940e1 9. Henderson LA, Canna SW, Friedman KG, et al. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 1. Arthritis Rheumatol. 2020;0(0):1-15. doi:10.1002/art.41454 10. Kumar A, Arora A, Sharma P, et al. Is diabetes mellitus associated with mortality and severity of COVID-19? A meta-analysis. Diabetes Metab Syndr Clin Res Rev. 2020;14(4):535-545. doi:10.1016/j.dsx.2020.04.044 11. Pazoki M, Keykhaei M, Kafan S, et al. Risk indicators associated with in-hospital mortality and severity in patients with diabetes mellitus and confirmed or clinically suspected COVID-19. J Diabetes Metab Disord. Published online 2021. doi:10.1007/s40200-020-00701-2 12. Gregory JM, Slaughter JC, Duffus SH, et al. COVID-19 Severity Is Tripled in the Diabetes Community: A Prospective Analysis of the Pandemic’s Impact in Type 1 and Type 2 Diabetes. Diabetes Care. 2020;44(2):dc202260. doi:10.2337/dc20-2260 13. Ge Y, Sun S, Shen Y. Estimation of case-fatality rate in COVID-19 patients with hypertension and diabetes mellitus in the New York State: A preliminary report. Epidemiol Infect. 2021;149. doi:10.1017/S0950268821000066 14. O’Malley G, Ebekozien O, Desimone M, et al. COVID-19 Hospitalization in Adults with

- 9 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

Type 1 Diabetes: Results from the T1D Exchange Multicenter Surveillance Study. J Clin Endocrinol Metab. 2020;106(2). doi:10.1210/clinem/dgaa825 15. Rubino F, Amiel SA, Zimmet P, et al. New-Onset Diabetes in Covid-19. N Engl J Med. 2020;383(8):789-790. doi:10.1056/nejmc2018688 16. Suwanwongse K, Shabarek N. Newly diagnosed diabetes mellitus, DKA, and COVID- 19: Causality or coincidence? A report of three cases. J Med Virol. 2021;93(2):1150- 1153. doi:10.1002/jmv.26339 17. Chang DJ, Moin T. Coronavirus disease 2019 and type 1 diabetes mellitus. Curr Opin Endocrinol Diabetes Obes. 2021;28(1):35-42. doi:10.1097/MED.0000000000000598 18. Bode B, Garrett V, Messler J, et al. Glycemic Characteristics and Clinical Outcomes of COVID-19 Patients Hospitalized in the United States. J Diabetes Sci Technol. 2020;14(4):813-821. doi:10.1177/1932296820924469 19. Zhu L, She ZG, Cheng X, et al. Association of Blood Glucose Control and Outcomes in Patients with COVID-19 and Pre-existing Type 2 Diabetes. Cell Metab. 2020;31(6):1068-1077.e3. doi:10.1016/j.cmet.2020.04.021 20. Sardu C, D’Onofrio N, Balestrieri ML, et al. Outcomes in Patients with Hyperglycemia Affected by COVID-19: Can We Do More on Glycemic Control? Diabetes Care. 2020;43(7):1408-1415. doi:10.2337/dc20-0723 21. Solerte SB, D’Addio F, Trevisan R, et al. Sitagliptin treatment at the time of hospitalization was associated with reduced mortality in patients with type 2 diabetes and covid-19: A multicenter case-control retrospective observational study. Diabetes Care. 2020;43(12):2999-3006. doi:10.2337/dc20-1521 22. Pasquel FJ, Umpierrez GE. Individualizing Inpatient Diabetes Management During the Coronavirus Disease 2019 Pandemic. J Diabetes Sci Technol. 2020;14(4):705-707. doi:10.1177/1932296820923045 23. Bornstein SR, Rubino F, Khunti K, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020;8(6):546-550. doi:10.1016/S2213-8587(20)30152-2 24. Rayman G, Lumb AN, Kennon B, et al. Dexamethasone therapy in COVID-19 patients: implications and guidance for the management of blood glucose in people with and without diabetes. Diabet Med. 2021;38(1). doi:10.1111/dme.14378 25. Lim S, Bae JH, Kwon HS, Nauck MA. COVID-19 and diabetes mellitus: from pathophysiology to clinical management. Nat Rev Endocrinol. 2021;17(1):11-30. doi:10.1038/s41574-020-00435-4 26. Korytkowski M, Antinori-Lent K, Drincic A, et al. A pragmatic approach to inpatient diabetes management during the COVID-19 pandemic. J Clin Endocrinol Metab. 2020;105(9):1-12. doi:10.1210/clinem/dgaa342 27. Scheen AJ. DPP-4 inhibition and COVID-19: From initial concerns to recent expectations. Diabetes Metab. Published online November 2020. doi:10.1016/j.diabet.2020.11.005 28. Cao Y, Gao F, Zhang Q, et al. Efficacy and safety of coadministration of sitagliptin with insulin glargine in type 2 diabetes. J Diabetes. 2017;9(5):502-509. doi:10.1111/1753- 0407.12436 29. Center for Disease Control and Prevention (CDC). Discontinuation of Transmission- Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) | CDC. Accessed May 14, 2020. - 10 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized- patients.html 30. Sharp HealthCare. Discontinuing COVID-19 Transmission-Based Precautions. Published online 2021.

- 11 - V7, updated 9/5/2021 Sharp HealthCare COVID-19 Treatment Guidelines (V7)

Supplemental References

NIH https://www.covid19treatmentguidelines.nih.gov/overview/

IDSA https://www.idsociety.org/practice-guideline/Covid-guideline-treatment-and- management/

ACOG https://www.acog.org/clinical/clinical-guidance/practice- advisory/articles/2020/03/novel-coronavirus-2019

Authors The authors of this document have no conflicts of interest or disclosures to report.

To reach the authors or to provide feedback on this document, please reach out to: General Editor:  Brian Lichtenstein, MD, Hospital Medicine ([email protected]) Section Authors:  Anticoagulation, Pulmonary Disease: Roland El Ghazal, MD, Pulmonology and Critical Care ([email protected])  Antimicrobials: Norihiro Yogo, MD, Infectious Disease ([email protected]), Louis Lteif, PharmD ([email protected])  Endocrinology: Kalman Holdy, MD, Endocrinology ([email protected]), Brandon Bailey, PharmD ([email protected])  Immunomodulators: Louis Lteif, PharmD ([email protected])  Lab Medicine: Omid Bakhtar, MD, Pathology ([email protected])  Obstetrics/MFM: Joanna Adamczak, MD, Maternal-Fetal Medicine ([email protected])

- 12 - V7, updated 9/5/2021