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Updated 5 November

You can find our COVID-19 guidance below.

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?

NICE has 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.


BSR has published guidance on how to restart services, based on the current impact of COVID-19 and key constraints, such as staffing levels and access to other key elements of practice such as imaging and infusion services

In Wales, some adult and paediatric rheumatology services have been included in the Welsh Government’s guidance; Maintaining Essential Health Services during the COVID 19 Pandemic – summary of services deemed essential. This updated advice should be read in conjunction with the Winter Protection Plan: NHS Wales Operating Framework Quarters 3&4, 2020/2


NICE has published guidance on arranging planned care in hospitals and diagnostic services to help healthcare professionals deliver efficient planned care while minimising the risk of COVID-19 in the context of increasing or decreasing local prevalence. It also aims to help patients make decisions about their planned care. It is for adults, young people and children in hospitals and diagnostic settings. Planned care covers elective surgery (day surgery and inpatient stays), interventional procedures, diagnostics and imaging. It does not include services where people have ongoing outpatient and day-case procedures such as chemotherapy, radiotherapy and dialysis.


Self-management resources for those with MSK conditions have been developed by the MSK Leadership Group, supported by NHS England and NHS Improvement. This helps with the delivery of virtual healthcare at this time.

How should services be prioritised in community settings?

NHS England has published a guide on Implementing phase 3 of the NHS response to the COVID-19 pandemic, which includes guidance on the restoration of adult and older people’s community health services. This document supersedes the earlier prioritisation guidance for community health services published on 20 March 2020. All services areas listed in the 20 March 2020 guidance should now be fully reinstated.

How do I determine whether my patient is clinically extremely vulnerable?

According to the government’s guidance on clinically extremely vulnerable people, adults on immunosuppression therapies sufficient to significantly increase risk of infection are considered clinically extremely vulnerable (CEV). CEV people will have previously received a letter from the NHS and/or their GP explaining what this means for them in the summer. They will also (if they haven’t already) receive a further letter explaining the new guidance during this second lockdown.


Please refer to our risk stratification guide for rheumatology, which provides more detail, in determining the level of risk to your patients and defining whether they are considered CEV. The CEV group are those patients who, in the guide, are in the 'Shield' column. With regards to children and young people, BSR's risk stratification guide has been superseded by the RCPCH shielding update.


A paper published in Clinical Medicine explaining the process undertaken to identify our patient group for shielding


England


Scotland


Wales


Northern Ireland


For other patients asking what precautions they should take, please refer them to Versus Arthritis’s patient information.

What's the latest advice for clinically extremely vulnerable people?

Clinically extremely vulnerable (CEV) people returning to work

In England, CEV people are advised to work from home, and if they are unable to do so, they are advised not to go to work. In Scotland, Wales and Northern Ireland the advice remains the same as before – CEV people may go to work if they are unable to work from home. We advise that patients are encouraged to request an individualised risk assessment by their employer where possible. When patients must attend in-person, they need to be able to maintain safe social distancing and have appropriate access to PPE, depending on their line of work.


England

In England, CEV people are encouraged to stay home as much as possible, but are encouraged to go outside for exercise.


CEV people may socialise with one person outside their household and support bubble in an outdoor public space for exercise. CEV people are advised not to go to the shops or pharmacy and should continue to seek support from the NHS and other health providers for existing health conditions and any new concerns, including to receive in-person care. You can find more information from the updated guidance on CEV people here.


The government will write to all clinically extremely vulnerable people (i.e. those on the Shielded Patient List) to set out detailed advice. In preparation for this, clinicians are urged to review their Shielding Patient List, including, where appropriate, removing children and young people.


Your Shielding Patient List must be complete and as accurate as possible so that individual patients are given the most appropriate advice. Information on maintaining in the Shielded Patient List can be found on the NHS Digital website.


Template letters are available through your COVID-19 Trust Lead for use when communicating with any of those patients currently in your care that you identify as either:


  • Needing to be added to the highest risk category and included in the Shielded Patient List. You do not need to send this to those patients you have previously identified as needing to shield
  • No longer needing to be identified as in the highest risk category and therefore to be removed from the Shielded Patient List.


The currency of this information is important for those highest-risk patients, who may need to be provided with additional information and support in the event of local lockdowns.


Scotland

Shielding has paused in Scotland, meaning clinically extremely vulnerable people can follow the same guidance as the rest of Scotland. The advice may differ locally depending on specific restrictions for lockdown. You can sign up for a text messaging service to send you updates and alert you when there is an increased risk in your area by sending your CHI number (at the top of your shielding letter) to 07860 064525. 


The Scottish Government has produced practical guidance for individuals with specific medical conditions, including those with rheumatic conditions and immunosuppression therapies for inflammatory disease.

Wales

Shielding in Wales has paused meaning clinically extremely vulnerable people may follow the same guidance as the rest of Wales. It is possible that shielding will be reinstated in the future in areas under lockdown. All those who were previously asked to shield will be written to directly if they are later required to shield again. You can find information about local areas in lockdown here.


Northern Ireland

Shielding in Northern Ireland has paused with no plans for it to restart at the moment. Social distancing should continue to be followed. Shielding may be reinstated if your patients live in an area with restrictions or local lockdown.

Should patients cease their medication as a precaution against COVID-19?

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.

How do I manage patients on long-term steroids at risk of adrenal suppression?

The Society for Endocrinology has produced guidance for management of patients with adrenal insufficiency who have COVID-19. This guidance applies to any patient who has been taking 5mg prednisolone or more for four weeks or longer, as this may cause adrenal insufficiency.


As noted in the British National Formulary, adrenal insufficiency due to steroid therapy can persist even after a patient has tapered their prednisolone dose below 5mg, so many rheumatology patients currently taking <5mg prednisolone are also at risk of adrenal insufficiency (see paper published in European Journal of Endocrinology).


Patients with adrenal insufficiency need to temporarily increase their steroid dose if they have any significant intercurrent infection. Patients with COVID-19 may have high fever or other systemic symptoms for many hours of the day. In COVID-19, therefore, the standard advice to double the prednisolone dose in the event of significant intercurrent illness may not be sufficient. This can be applied to rheumatology patients as follows:


  • Patients on 5-15 mg prednisolone daily should take 10 mg prednisolone every 12 hours

  • Patients on oral prednisolone >15 mg should continue their usual dose but take it split into two equal doses of at least 10 mg every 12 hours

  • Patients with COVID-19 may have large insensible water losses, and should be advised to drink plenty of fluids especially if they may have adrenal insufficiency

  • Patients can be issued with the new NHS emergency steroid card which signposts healthcare providers to the latest guidance on management of adrenal crisis

What’s the most appropriate treatment option if treatment needs starting or escalating?

Patients will be nervous about starting any treatment that might increase their risk of infection. A discussion on treatment options should take place that should include consideration of demographic factors and co-morbidities known to be associated with increased risk of serious infection and complications of COVID-19 (e.g. increasing age, especially >70 years, or for those with co-morbidities such as diabetes mellitus, chronic lung disease and ischaemic heart disease).


For patients starting DMARDS, consider using those with a shorter half-life (particularly for those at highest risk of serious infection and complications of COVID-19). If appropriate, opt for sulfasalazine and/or hydroxychloroquine rather than methotrexate or leflunomide.

Similarly, for patients starting biologic or small molecule inhibitors or switching biologic drugs, careful discussion with the patient is essential, taking into account patient-specific risk factors that increase risk of serious infection and complications of COVID-19.


If there is significant disease activity and the patient understands the risk, then it is acceptable to move forward with these drugs. Again, we advise considering the use of drugs with the shortest half-life (eg etanercept, JAKi). We're aware that some homecare providers stopped new registrations and were not sending out nurses to demonstrate how to give the first injection, but these problems have now been resolved.

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.


We have supported guidance on the management of patients with musculoskeletal and rheumatic conditions who are on corticosteroids, require initiation of oral/IV corticosteroids and require corticosteroid injection. This updates the previous guidance, and can be read here.


What is the role of Vitamin D supplementation?

NHS England: guidance on vitamin D supplementation (revised guidance is that if you're not going outdoors often, you should consider taking a daily supplement with 10 micrograms of vitamin D

Are there sufficient supplies of hydroxychloroquine (HCQ) in the UK?

We raised this with NHS England, the Welsh Government. the Department for Health in Northern Ireland and the Scottish Parliament, and have been assured that sufficient supplies are currently available in all four nations. Stock has reportedly been low in England, but further supplies have now been released to wholesalers. The MHRA has added HCQ to the list of medicines that cannot be parallel-exported from the UK, in order to protect stock for UK patients. Relevant pharmacies should therefore be able to order what they need. If this is not the case, please contact us.

What about frequency of blood testing?

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 immunosuppressed 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.

What's the latest advice for children, young people and their families?

PIMS-TS

In the last few months a small number of children and young people were identified as acutely unwell, often requiring paediatric intensive care unit (PICU) input, with an unusual hyperinflammatory condition (PIMS-TS). This rare syndrome shares common features with other paediatric inflammatory conditions including Kawasaki disease and forms of toxic shock syndrome. The RCPCH has produced guidance to address this.


The British Paediatric Surveillance Unit (BPSU) has launched a system for reporting cases of PIMS-TS. BPSU is a centre for rare paediatric disease surveillance, investigating how many children in the UK and Republic of Ireland are affected by particular rare diseases, conditions or treatments each year.


COVID-19

What's the updated shielding guidance and advice on returning to school for children and young people (CYP)?

The RCPCH’s advice has changed due to evidence available across Europe. There is no evidence that children and young people with rheumatological or inflammatory conditions are more likely to be infected with COVID-19 than those without, nor is there any evidence that if infected with COVID-19, that they will become more unwell compared to children without these conditions. This includes individuals on immunosuppressive medications. These children and young people should now attend school in accordance with government advice.


Please refer to the RCPCH guidance for more information. The update is under ‘notes on other conditions’.


Medical Directors and Paediatric Clinical Directors will cascade lists to paediatricians as a matter of urgency. This list contains the names of patients classified as clinically extremely vulnerable. Paediatricians are being asked to review that list in line with RCPCH advice, and take steps to remove patients who are inappropriately listed. If children are not removed from this list, and shielding is reinstated, it is highly likely that children will be removed from school settings inappropriately.


Additional advice:

Is there any specific advice for health professionals considered at risk?

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. Healthcare professionals should follow the advice of their rheumatology team.

According to emerging UK and international data, people from Black, Asian and Minority Ethnic (BAME) backgrounds are being disproportionately affected by COVID-19. The Department for Health and Social Care asked Public Health England to investigate; prior to the publication of their report and guidance, on a precautionary basis, it's recommended by the NHS that employers should risk-assess staff at potentially greater risk and make appropriate arrangements accordingly.

Is there any rheumatology-specific data on the impact of coronavirus to date?

Research exploring the effectiveness of various rheumatic drugs in treating COVID-19 is underway; information remains limited at this stage. COVID-19 appears to affect children, young people and adults differently, with infections milder in children, although we don’t yet know exactly why this is the case.


We are supporting two initiatives helping inform practice:


  • EULAR COVID-19 Database: the European Data portal for EU and other European patients (children, young people and adults) is now live. The database isn’t classed as a research study and UK NHS ethics approval is not required. There’s no requirement for patient consent and the database collects anonymised patient data only. Clinicians are encouraged to report all cases of COVID-19 in their rheumatology patients, regardless of severity, and to report cases where there’s been a high suspicion of COVID-19, and to indicate that this is unconfirmed. Reporting a case should take 5-7 minutes

  • European Patient Registry: EULAR and PRES support a patient self-report register. Patients register and enter their own data

What ongoing trials are there?

  • RECOVERY trial: four different treatment regiments for COVID-19

  • RECOVERY 2: further randomisation of patients who’ve already consented and been rand randomised to the RECOVERY trial. If they remain unwell with a CRP > 75mg/L and an ongoing requirement for oxygen, they’ll receive either standard care or a single infusion of Tocilizumab, which can be repeated 12-24 hours after the first if there’s an inadequate response


Rheumatologists have much more familiarity with and experience of the use and risks of Tocilizumab than acute physicians and intensivists likely to be responsible for the clinical care of these patients, and we encourage all UK rheumatologists to contact their local R&D Leads if they have not already done so to discuss how they can support recruitment to RECOVERY2. 

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.


For advice specific to any of the devolved nations, please refer to each nation's public health body:


What resources are available to patients recovering from COVID-19?

Your COVID Recovery is now live. It's a new NHS website providing health advice, guidance and links to support for people who have ongoing symptoms and health needs after having COVID-19. There are specific sections about fatigue and musculoskeletal, shoulder and back pain.