NICE has developed guidelines is to maximise the safety of patients with rheumatological autoimmune, inflammatory and metabolic bone disorders during the COVID-19 pandemic. Here, Univadis provides a summary of key recommendations.
General recommendations
- Communicate with patients and support their mental wellbeing, signposting to charities and support groups where available.
- Minimise face-to-face contact.
- Advise patients to contact NHS 111 by phone or via the website for advice on COVID‑19.
- Patients should contact their rheumatology team about rheumatological medicines or if their condition worsens.
- Be aware that patients having immunosuppressant treatments may have atypical presentations of COVID‑19 e.g. patients taking prednisolone may not develop a fever, and those taking interleukin‑6 inhibitors may not develop a rise in C‑reactive protein.
- If a patient not previously known or suspected to have COVID‑19 shows symptoms at presentation, follow UK government guidance on investigation and initial clinical management of possible cases.
- Discuss with each patient the benefits of treatment compared with the risks of COVID-19.
- Think about whether any changes to medication are needed e.g. dosage, route of administration, and mode of delivery.
Non-steroidal anti-inflammatory drugs
- Patients taking NSAIDs for long-term conditions should continue treatment.
Corticosteroids
- Patients taking prednisolone should continue treatment.
- Only use methylprednisolone for treating major organ flares.
- Consider using oral corticosteroids.
Biological treatments
- Assess whether patients having intravenous treatment can be switched to subcutaneous treatment (e.g. tocilizumab, abatacept, belimumab).
- Assess whether patients on infliximab can be switched to an alternative subcutaneous TNF inhibitor.
- Assess whether maintenance treatment with rituximab can be reduced to 1 pulse or the duration between treatments increased.
Immunoglobulins
- Assess whether the frequency of intravenous immunoglobulins can be reduced for day-care patients.
Bisphosphonates and denosumab
- Do not postpone treatment with denosumab.
- Treatment with zoledronate can be postponed for ≤6 months.
- Do not postpone treatments for digital ulcer disease.
- Ensure patients having intravenous prostaglandins have had the maximum dose of sildenafil and whether they can be switched to bosentan.
Drug monitoring
- Assess whether it is safe to increase time intervals between blood test, particularly if three‑monthly blood tests have been stable for ≥2 years.
- Follow recommended blood monitoring guidelines for patients starting a new DMARD.
Modifications to usual care
- Only continue core services, such as rheumatology department advice lines; essential parenteral day-case treatment; blood tests for drug monitoring; on-call cross-consultant services for urgent review
- Maintain specialised rheumatology networks and virtual multidisciplinary team meetings.
Primary care
- Provide rheumatology department advice lines, run by staff with appropriate knowledge, to provide advice to primary care and community colleagues.
- Prioritise urgent and emergency musculoskeletal.
- Prioritise musculoskeletal rehabilitation for patients who have had recent elective surgery or a fracture, and for those with acute or complex needs (including carers).
Outpatients
- For urgent new referrals and follow-ups for suspected inflammatory arthritis, suspected autoimmune connective tissue diseases and vasculitis, screen for COVID-19 symptoms by phone or virtually.
Day care
- Prioritise based on the urgency of a patient's condition.
Inpatients
- Maintain rheumatology ward cover, and an out-of-hours on-call service if possible.
References
References
