Updated 7 April
Members are receiving a large number of queries in relation to COVID-19 (Coronavirus), and the risk to their patients’ health. Current advice is that the risk to the general population in the UK is now high.
Our advice is drawn from a number of sources, covers adults, children and young people, and is updated at the situation evolves.
This advice is for clinicians. Patients looking for further information on whether their condition places them in a higher-risk category, or about precautions they should take, are advised to speak to their clinical team, who are best placed to answer specific questions. Versus Arthritis has produced a guide for patients covering some of the most frequently asked questions.
Is there any specific advice on how patients should be managed during this pandemic?
BSR has been working closely with NHS England to develop resources to guide our members on how to manage their patients. NHS England has published specialty guides on managing patients during the coronavirus pandemic:
These clinical guides explain what steps units should take and how resources should be allocated as infection rates increase.
NICE has now also published a ‘rapid guideline’ on rheumatological autoimmune, inflammatory and metabolic bone disorders, focusing on how to manage disorders during the COVID-19 pandemic, while protecting staff and patients from infection. It also enables services to make the best use of NHS resources.
Self-management resources for those with MSK conditions have also been developed by the MSK Leadership Group, supported by NHS England and Improvement. This helps with the delivery of virtual healthcare at this time.
How should services be prioritised in community settings?
NHS England’s guide on prioritising COVID-19 in community services provides information on how community services can release capacity to support the COVID-19 response. Members should refer to the sections on MSK services (pg. 12) and phlebotomy (pg. 16). Included in the guide are the following points:
Aligned with orthopaedic and rheumatology planning, MUST prioritise triage to enable continued referral of emergency and urgent MSK conditions to secondary care services
Rehabilitation MUST prioritise patients who have had recent elective surgery, fractures or those with acute and/or complex needs, including carers, with a focus to enable self-management
All other rehabilitation work should be stopped, with patients enabled to self-manage (this includes rehabilitation groups)
Where appropriate, virtual and telephone consultations to be implemented
Introduce telephone triage to assess risks of serious complications e.g. Cauda Equina syndrome.
How should I determine the level of risk to my patients of COVID-19 and advise them on what precautions to take?
Please refer to our risk stratification guide and scoring grid for rheumatology, which will help identify which precautions adult, paediatric and adolescent patients should take. This advises on whether patients should shield, self-isolate or social distance at patient discretion or maintain social distance due to their level of risk. These categories are based on vulnerability due to condition(s) and medication(s). Patients you advise to practice shielding should be directed to Public Health England’s guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19.
For other patients asking what precautions they should take, please refer them to Versus Arthritis’s patient information.
Why do risk levels differ between the NHS England guide to patient management (published 16 March) and BSR guidance (published 22 March)?
The remit of the NHS England guide was to identify patients who may be at higher risk due to COVID-19, without indicating what particular action should be taken. This included the following reference: “The receipt of any biologic probably puts the patient in the high or very high category.”
The remit of the BSR guidance was to provide more specific advice in relation to those patients most at risk, and together with the Government's announcement on the need for 1.5m patients in England to shield.
How are the 1.5m vulnerable patients being identified?
NHS England is identifying a high-risk group of up to 1.5m patients across England, who are being asked to shield for their own protection and for whom they will provide a degree of enhanced support. The devolved nations have adopted a similar approach based on BSR guidance.
While 900,000 adults and children across England have been identified so far through NHS digital coding, there are some patients at high risk who will not be identified via this route. We are asking for members’ help in identifying these patients.
Once you have identified which of your patients are at the highest risk level, advise them and your Trust's named COVID-19 lead. NHS Digital will be in touch with every lead about the ongoing process for transferring this information to the central registry.
Some patients may have been identified as needing to shield by NHS England, but would not typically be characterised as being at high risk by those providing their care. These patients may have received a text message if they are taking certain immunosuppressive drugs (e.g. Azathioprine, mycophenolate, tacrolimus, sirolimus). This precaution was taken to protect as many people as possible while specialty advice was confirmed.
Not all patients on these medications should be contacted, but members should be aware why some patients may have received this information. It is at the clinician’s discretion to review the guidance and advise appropriately on an individual patient basis.
Should patients cease their medication as a precaution?
All patients, including those aged 16 years and under, should continue to take their medication unless directed otherwise by their rheumatology team or GP. If you are planning to start or switch a patient to a new medication this may now need to be reviewed. Patients on long-term glucocorticoids (steroids, prednisolone) should not stop these abruptly.
If patients develop symptoms of any infection, established practice should be followed and immunosuppressive therapy paused for the duration of the infection and until they feel well, in consultation with their rheumatology team. For those on glucocorticoids, the expectation is that treatment should not be stopped abruptly and advice should be sought from their treating team.
Starting and or escalating treatment during COVID-19?
Patients will be nervous about starting any treatment that might increase their risk of infection. A discussion on treatment decisions should take place, including consideration that deferring starting treatment (biologics or DMARDs) might be the correct approach. Please be aware that co-morbidities significantly increase the risk of serious infection with COVID-19, and any decision to start treatment in patients >70 years, or for those with pre-existing Diabetes Mellitus, lung disease, IHD or hypertension must be considered carefully.
What’s the most appropriate treatment option if treatment needs starting or escalating?
For patients starting DMARDS, consider using those with a shorter half-life. If appropriate, opt for sulphasalazine and/or hydroxychloroquine rather than methotrexate or leflunomide. For patients starting biologic or small molecule or switching biologic drugs, please discuss carefully with them; the risk of infection is highest in the first 4-6 months after starting treatment.
If there is significant disease activity and the patient understands the risk, then it is acceptable to move forward with these drugs. Otherwise, we recommend considering postponing starting treatment for 2-3 months. Again, we advise considering the use of drugs with the shortest half-life (eg Etanercept, JAKi). Please note: some homecare providers have stopped new registrations, so you may have to come up with a local alternative arrangement for issuing prescriptions (eg FP10s).
Some providers are no longer sending nurses out to demonstrate how to give the first injection - this is something that needs an alternative arrangement.
Should I still be injecting corticosteroids during the current COVID-19 pandemic?
As is current practice, injections must not be undertaken in individuals with active infections. In the current situation, the potential therefore arises to do harm to those who may be incubating or later develop COVID-19. Current WHO guidance for the management of severe acute respiratory infection in patients with COVID-19 is to avoid giving systemic corticosteroids unless indicated for another reason.
There has been some concern about the use of non-steroidal anti-inflammatory medications (NSAIDs) in relation to COVID-19, following recent comments by the French authorities. In the absence of conclusive evidence, the Committee of Human Medicines (an advisory body of MHRA) and NICE have been asked to review the evidence. For now, advice for patients with confirmed or suspected COVID-19 is to use paracetamol in preference to NSAIDs. Those currently on NSAIDs for other medical reasons (e.g. arthritis) should not, however, stop them.
We have separate guidance on this. Read the separate statement here.
Are there sufficient supplies of hydroxychloroquine available in the UK?
BSR has raised this with NHS England and been assured that sufficient supplies are currently available in the UK. Stock has reportedly been low, but further supplies have now been released to wholesalers. Therefore, relevant pharmacies should be able to order what they need. If this is not the case, please contact us.
What about frequency of blood testings?
Members may need to be flexible about blood testing for patients on stable DMARDs in the current pandemic. It is usually safe to reduce blood testing frequency to three-monthly or even less in stable patients. Departments will need to review cases on an individual basis and weigh up the risks of continuing without blood testing, compared to the benefit of staying on DMARDS.
Should immunosupressed patients be offered alternative clinic appointments?
Clinicians should now look to remove the need for patients to attend face-to-face appointments wherever possible. This might involve telephone appointments or video consultations; NHSX and the Information Commissioners Office have permitted the NHS to use WhatsApp/FaceTime/Skype for patients given the urgent nature of the situation. Please see this NHS guidance for more.
Is there any other advice relevant to children, young people and their families?
The principles of this guidance cover all patients. Where possible, units should contact families to share advice in an accessible format, like this video from the Paediatric Rheumatology European Society (PRES).
Other resources include guidance published by PHE on supporting children and young person’s mental health and wellbeing.
What steps should units undertake to effectively prepare for an increase in infected patients?
The NHS has published advice (table 3) on the prevalence of COVID-19 infection and associated available hospital resources.
Each NHS organisation has an Accountable Emergency Officer (AEO) who is responsible for overseeing preparations. Their role includes:
Acute care providers have also been asked to undertake a number of steps, including:
Reviewing all pathways, specifically those in 'medicine' that support those with respiratory illness and considering the impact a possible surge in medical patients might have on services and stocks
Reviewing critical care and high dependency capacity and consider how this could be increased and the impact of doing so.
Is there any specific advice for health professionals considered part of high-risk groups, such as those with rheumatic conditions?
Specific advice is currently being developed by NHS England and Public Health England. While waiting for this advice, immunosuppressed healthcare workers should ensure that their line manager/clinical lead, occupational health and treating rheumatologist are all aware of their medication and scope of practice.
Is there any rheumatology-specific data on the impact of coronavirus to date?
We are aware that research is underway to explore the effectiveness of a number of rheumatic drugs in treating coronavirus, although information remains limitedd at this stage. COVID-19 also appears to affect children, young people and adults differently, with infections milder in children, although we do not yet understand exactly why this is the case.
BSR is supporting the launch of two initiatives to help inform practice:
COVID-19 Global Rheumatology Registry: the European Data portal for EU and other European patients (adults, young people and children, accessible via EULAR's website) will be live shortly. We will share further details about how clinicians can submit data as soon as we have them.
European Patient Registry: EULAR and PRES are supporting a patient self-report register. Patients register and enter their own data
Data on the UK rate and severity of coronavirus infection in patients with rheumatic conditions is also expected to be gathered in the coming weeks.
Where can I access further advice?
The most up-to-date advice and guidance for clinicians can be found here. We would encourage members and patients to refer to this information for any queries. If you’d like to discuss a specific issue, you can also contact the Policy team.
All BSR members can access a dedicated forum by visiting the myBSR section of our website, where you can discuss recent developments with colleagues, pose questions or share local practice/guidance.
For advice specific to any of the devolved nations, please refer to each nation's public health body: