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The purpose of this guideline is to maximise the safety of children and adults who have gastrointestinal or liver conditions treated with drugs affecting the immune response during the COVID-19 pandemic. It also aims to protect staff from infection and enable services to make the best use of NHS resources.

This Guidelines summary only covers recommendations relevant to primary care. For the complete set of recommendations, please see the full guideline.

Communicating with patients and minimising risk

Patients not known to have COVID-19

  • Minimise time in the waiting area by:
    • careful scheduling
    • encouraging patients not to arrive early
    • texting patients when you are ready to see them, so that they can wait outside, for example, in their car
    • delivering treatment promptly
    • ensuring prescriptions are dispensed rapidly
  • Be aware that worsening gastrointestinal symptoms and deteriorating liver function test results could be associated with COVID-19
  • Be aware that patients taking drugs that affect the immune response may have atypical presentations of COVID-19. For example, patients taking corticosteroids may not develop a fever
  • Be aware that patients with decompensated liver disease may be at higher risk of severe COVID-19 when taking drugs affecting the immune response.

Treatment considerations

  • Balance the risks of drugs that affect the immune response with the risks of active disease 
  • When deciding whether to start a new treatment with a drug that affects the immune response, discuss the risks and benefits with the patient or their parents or carers, and take into account the following in the context of COVID-19:
    • has the patient had COVID-19 vaccination?
    • is it essential to start this drug immediately?
    • if treatment is needed, is there an alternative with a better risk profile
    • is the required monitoring and review feasible?
    • can monitoring be done remotely or at a frequency that minimises the risk to the patient’s safety and wellbeing?
  • If a patient is having or going to be having immunosuppressive treatments, follow the advice on COVID-19 vaccination in the Green Book and the Specialist Pharmacy Service advice on using COVID-19 vaccines in patients taking immunosuppressive medicines
  • For patients who are already taking drugs that affect the immune response, continue with existing courses of treatment to minimise the risk of a flare-up. Think about whether any changes are needed to minimise face-to-face contact during the COVID-19 pandemic, including:
    • dosage
    • route of administration
    • mode of delivery
  • For patients who are stable on treatment, assess whether it is safe to do less frequent blood tests for drug monitoring. Take into account the patient’s age and any co-morbidities.

Patients known or suspected to have COVID-19

Treatment considerations

  • In patients with symptoms of COVID-19:
    • do not suddenly stop oral or rectal corticosteroids
    • contact the gastroenterology or hepatology team for urgent advice before changing or stopping any drugs that affect the immune response
  • When deciding whether to stop treatment, discuss the risks and benefits with the patient or their parents or carers, and take into account:
    • whether COVID-19 is confirmed
    • the severity of the COVID-19
    • the risks and benefits of stopping or continuing treatment
    • the severity of the gastrointestinal or liver condition
    • the effect of stopping treatment on other conditions
    • other risk factors such as age and co-morbidities (for example respiratory or cardiovascular conditions).

Modifications to usual care

  • Think about how to modify usual care to reduce patient exposure to COVID-19 and make best use of resources (workforce, facilities, equipment).

Supplying medicines

  • Put plans in place to manage potential disruptions to the supply of medicines during the COVID-19 pandemic
  • Do not prescribe larger than usual quantities of medicines, because this puts the supply chain at risk.


© NICE 2021. COVID-19 rapid guideline: gastrointestinal and liver conditions treated with drugs affecting the immune response. Available from: nice.org.uk/ng172. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication

Published date: 23 April 2020.

Last updated: 09 April 2021.