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Updated 23 June

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.

Latest updates:

  • Updated shielding advice for England and Northern Ireland

  • Updated MSK and rheumatology corticosteroid guidance

  • RCPCH updated shielding guidance and advice on returning to school for children and young people

  • NHSE operating framework for urgent and planned services within hospitals

  • BSR guidance on restarting services

Is there any specific advice on how patients should be managed during this pandemic?

We've worked 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.


NHS England updated its clinical guide for the management of rheumatology patients during the coronavirus pandemic (see above). The content remains similar to the previous version, with a new paragraph providing context on the exercise to identify vulnerable patients that require shielding. This guidance provides clarification that our risk stratification for shielding is the gold standard, and should be followed to ensure a consistent approach in paediatric, adolescent and adult rheumatology units.

BSR has published new 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.


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 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.


The Scottish Government has guidance for shielding, as well as specific guidance for those with rheumatic conditions. Local health boards are using the National Video Conferencing Service to provide remote consultations.


In a letter about the second phase of NHS response to COVID-19, Sir Simon Stevens, NHS Chief Executive and Amanda Pritchard, NHS Chief Operating Officer recommend the following:


  • All NHS secondary care providers in England now have access to video consultation technology to deliver some clinical care without the need for in-person contact

  • As far as practicable, video or telephone appointments should be offered by default for all outpatient activity without a procedure, and unless there are clinical or patient choice reasons to change to replace with in-person contact

  • Trusts In England should use remote appointments - including video consultations - as a default to triage their elective backlog. They should implement a ‘patient initiated follow up’ approach for suitable appointments - providing patients the means of self-accessing services if required

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.


Additionally, NHS England recently published guidance for children with MSK conditions.

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 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.


We recently removed our scoring grid, initially developed to assist clinicians in identifying patients for shielding; it was never intended to be used by patients to self-identify, though we are aware that the latter approach has been used in a number of areas. There are also some minor discrepancies between the scoring grid and the risk stratification guidance, although it is important to highlight that the grid reliably identifies all patients who meet the shielding criteria, which was its primary purpose.


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


England


Scotland


Wales


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

What's the latest advice on shielding?

England

In England, changes to the shielding guidance will be implemented in two stages over the next few weeks. Shielding guidance will be relaxed from 6 July, subject to continued favourable epidemiological developments. From 6 July, those shielding will be advised to follow stringent social distancing guidance, rather than full shielding measures. Shielding will then be paused from 1 August. The Government is developing a more individualised approach to identified individuals who are clinically vulnerable to COVID-19. This approach will be supported with a risk stratification tool being developed by a research consortium led by the University of Oxford's Nuffield Department of Primary Care Health Sciences. The research protocol for this tool is available here.


Scotland

In Scotland, it remains necessary to shield until 31 July. Patients in shielding group 5 were identified by cross-referencing information provided by secondary care on prescription of biologic drugs and other secondary care prescriptions with primary care and other centrally held data, using an algorithm similar to the BSR stratification guide.


All patients that have been identified have been sent letters, advising them to adhere to shielding practices. Any additional patients identified by clinicians as at very high risk can be added to the shielding register through your Local Coordinating Team, in your Local Health Board. Guidance on shielding is available here.


Wales

The Chief Medical Officer for Wales has advised that shielding should continue until the 16 August 2020. A letter is being sent to everyone in Wales who is shielding to tell them this and what to do next.


NHS Wales has taken a very similar approach to NHS England in identifying vulnerable patients. More information can be found here. Members in Wales have raised concerns that rheumatology patients might be missed and we understand that many rheumatology departments in Wales have been identifying patients and sending out letters. The Chief Medical Officer for Wales advises that shielding should continue until 16 August. A letter is being sent to all those shielding in Wales to tell them this and what to do next.


Northern Ireland

From 6 July, people who are shielding will be able to meet up to six people outside the home, as long as strict social distancing is observed. People shielding and living alone will be able to form a support bubble. Shielding will be put on hold from 31 July.


Northern Ireland's Department of Health contacted all GPs to identify patients in need of shielding. Rheumatology teams also identified patients, using NHS England and BSR guidance, and issued letters based on our advice to all patients on biologic drugs. Where care arrangements are shared, GPs and/or rheumatology multidisciplinary teams further identified individuals from treatment groups and clinic lists who were considered high risk.

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

I need to start or escalate treatment with a patient

Patients will be nervous about starting any treatment that might increase their risk of infection. A discussion on treatment options 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 sulfasalazine 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.

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.


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.

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)?

Over the last few weeks, BSR has worked with the RCPCH to review the evidence and revise the advice on which CYP are ‘clinically extremely vulnerable’ to COVID-19 infection and therefore should continue to shield. 

The guidance addresses those who are extremely vulnerable (A) and those where their condition or situation may need further discussion regarding shielding (B). There are now far fewer CYP with rheumatological conditions who need to shield.


Group A: CYP with rheumatological conditions who are at highest risk


These patients should continue shielding as before and shouldn't return to school currently. These patients are:

  • On cyclophosphamide
  • Oon high-dose steroids, defined as >/= 0.5mg/kg/day, for four or more weeks within the last four weeks


This does not include topical steroid eye drops (if no oral/IV steroids were used)


Group B: CYP with rheumatological conditions where overall health status (unstable/flaring disease) and social circumstances requires discussion regarding shielding


There will be a few children who develop unstable disease and need medication escalation. These situations should be managed case-by-case by the holding clinical team, e.g. young person with an SLE flare; the combination of uncontrolled inflammation and a need for medication rescue may lead to a discussion regarding shielding. This is a clinician decision for an individual patient, considering overall health status and social circumstances.

What advice is there for CYP with rheumatological conditions who don't need to shield?

Patients who are stable, both on and off medications (including DMARDS and biologics) should carefully follow advice given to the general population on social distancing. They can, where possible, go back to school; this is important for physical and emotional wellbeing. There will understandably be some families who are anxious and local teams will continue to provide support in these situations.

Additional advice:

What steps should units undertake to effectively prepare for an increase in infected patients?

NHS England 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:


  • Keeping members of staff informed of advice from PHE and NHS England and Improvement

  • Ensuring medicine levels are maintained at levels proportionate to anticipated short term demand


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 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.


Our 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: