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Overview

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

  • Communicate with patients, their families and carers, and support their mental wellbeing to help alleviate any anxiety and fear they may have about COVID-19. Signpost to charities (such as Crohn’s & Colitis UK, the British Liver Trust, the Crohn’s in Childhood Research Association, and the Children’s Liver Disease Foundation), support groups (including NHS Volunteer Responders) and UK Government guidance on the mental health and wellbeing aspects of COVID-19
  • Provide patients, their families and carers with information that meets their communication needs (see NHS England’s Accessible Information Standard)
  • Some patients will have received a letter telling them they are at high risk of severe illness from COVID-19. Tell them, or their parents or carers:
  • Telephone, email or text patients booked for a gastroenterology or hepatology appointment, or their parents or carers. Tell them:
    • not to stop or change their medication without discussing with their gastroenterology or hepatology team first
    • that they can continue taking aminosalicylates, and that these drugs do not affect the immune response
    • to write down a list of the medicines they take and any conditions they have, to give to healthcare staff if they need to seek treatment for COVID-19
  • Minimise face-to-face contact by:
    • using telephone, video, or email consultations whenever possible
    • cutting non-essential face-to-face appointments
    • contacting patients via text message, telephone, or email
    • using electronic prescriptions rather than paper
    • using different methods to deliver prescriptions and medicines, for example, pharmacy deliveries, postal services, NHS Volunteer Responders, or introducing drive-through pick-up points for medicines
    • extending intervals between drug monitoring (see the recommendation on treatment considerations for patients known or suspected to have COVID-19) and using local services for blood tests if possible
  • If patients need to attend face-to-face appointments, ask them to help reduce the risk of contracting or spreading COVID-19 by:
    • coming to the appointment alone
    • having only one parent or carer accompany a child or adult who cannot come alone
    • avoiding public transport if possible
  • Tell patients who still need to attend services to follow relevant parts of UK Government guidance on social distancing for everyone in the UK, and UK Government advice on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19
  • Tell patients, and their families and carers, that they should contact the NHS 111 online coronavirus service if they think they have COVID-19. In an emergency they should call 999 if they are seriously ill. They should also contact their gastroenterology or hepatology team to get advice about any drugs they are taking that affect the immune response.

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.