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Overview

This Guidelines summary provides key information for primary care on the assessment, monitoring, and treatment of patients who present to general practice with symptomatic COVID-19.

View this summary online at guidelines.co.uk/456723.article

Adult primary care COVID-19 assessment pathway

Algorithm 1: Adult primary care COVID-19 assessment pathway

Adult primary care COVID-19 assessment pathway v4

Eligibility for COVID Medicines Delivery Unit referral

Table 1: Eligibility for COVID Medicines Delivery Unit referral

CohortDescription

Down’s syndrome

  • All patients with Down’s syndrome

Sickle cell disease

  • All patients with a diagnosis of sickle cell disease

Patients with a solid cancer

  • Active metastatic cancer and active solid cancers (at any stage)
  • All patients receiving chemotherapy within the last 3 months
  • Patients receiving group B or C chemotherapy 3–12 months prior
  • Patients receiving radiotherapy within the last 6 months

Patients with a haematologic malignancy

  • Allogeneic HSCT recipients in the last 12 months or active GVHD regardless of time from transplant (including HSCT for non-malignant diseases)
  • Autologous HSCT recipients in the last 12 months (including HCST for non-malignant diseases)
  • Individuals with haematological malignancies who have:
    • received CAR-T cell therapy in the last 24 months, or
    • radiotherapy in the last 6 months
  • Individuals with haematological malignancies receiving SACT within the last 12 months, except patients with chronic phase CML in molecular response or first- or second-line TKIs
  • All patients with myeloma (excluding MGUS) or chronic B-cell lymphoproliferative disorders (e.g. chronic lymphatic leukaemia, follicular lymphoma) or MDS who do not fit the criteria above
  • All patients with sickle cell disease
  • Individuals with non-malignant haematological disorder (e.g. aplastic anaemia or paroxysmal nocturnal haemoglobinuria) receiving B-cell depleting systemic treatment (e.g. anti-CD20, ATG, and alemtzumab) within the last 12 months

Patients with renal disease

  • Renal transplant recipients (including those with failed transplants within the past 12 months), particularly those who:
    • received B-cell depleting therapy within the past 12 months (including alemtuzumab, rituximab [anti-CD20], ATG)
    • have an additional substantial risk factor which would in isolation make them eligible for nMABs or oral antivirals
    • had not been vaccinated prior to transplantation
  • Non-transplant patients who have received a comparable level of immunosuppression
  • Patients with CKD stage 4 or 5 (an eGFR <30 ml/min/1.73 m2) without immunosuppression

Patients with liver disease

  • Patients with cirrhosis Child’s-Pugh class B and C (decompensated liver disease)
  • Patients with a liver transplant
  • Liver patients on immune suppressive therapy (including patients with and without liver cirrhosis)
  • Patients with cirrhosis Child’s-Pugh class A who are not on immune suppressive therapy (compensated liver disease)

Patients with IMIDs

  • IMID treated with rituximab or other B-cell depleting therapy in the last 12 months
  • IMID with active/unstable disease on corticosteroids, cyclophosphamide, tacrolimus, cyclosporin, or mycophenolate
  • IMID with stable disease on either corticosteroids, cyclophosphamide, tacrolimus, cyclosporin, or mycophenolate
  • IMID patients with active/unstable disease, including those on biological monotherapy and on combination biologicals with thiopurine or methotrexate

Primary immune deficiencies

  • CVID
  • Undefined primary antibody deficiency on Ig (or eligible for Ig)
  • Hyper-IgM syndromes
  • Good’s syndrome (thymoma plus B-cell deficiency)
  • SCID
  • Autoimmune polyglandular syndromes/APECED syndrome
  • Primary immunodeficiency associated with impaired type 1 interferon signalling
  • X-linked agammaglobulinaemia (and other primary agammaglobulinaemias)

HIV/AIDS

  • Patients with high levels of immune suppression, who have uncontrolled/untreated HIV (high viral load), or who present acutely with an AIDS-defining diagnosis
  • On treatment for HIV with CD4 <350 cells/mm3 and stable on HIV treatment or CD4 >350 cells/mm3 and additional risk factors (e.g. age, diabetes, obesity, cardiovascular, liver or renal disease, homeless, those with alcohol dependence)

Solid organ transplant recipients

  • All recipients of solid organ transplants not otherwise specified above

Rare neurological conditions

  • Multiple sclerosis
  • Motor neurone disease
  • Myasthenia gravis
  • Huntington’s disease

Abbreviations: AIDS=acquired immunodeficiency syndrome; APECED=autoimmune polyendocrinopathy candidiasis ectodermal dystrophy; ATG=anti-thymocyte globulin; CAR=chimaeric antigen receptor CD=cluster of differentiation; CKD=chronic kidney disease; CML=chronic myeloid leukaemia; CVID=common variable immunodeficiency; eGFR=estimated glomerular filtration rate; GVHD=graft versus host disease; HSCT=haematopoietic stem cell transplant; HIV=human immunodeficiency virus; IMID=immune-mediated inflammatory disorder; Ig=immunoglobulin; IgM=immunoglobulin M; MDS=myelodysplastic syndrome; MGUS=monoclonal gammapathy of unknown significance; nMABs=neutralising monoclonal antibodies; SACT=systemic anti-cancer treatment; SCID=severe combined immunodeficiency; TKI=tyrosine kinase inhibitor

For information on eligibility for the PANORAMIC study, refer to the full guideline.

COVID Oximetry @home monitoring

  • As per Algorithm 1, patients who are at higher risk and are well enough to be managed at home should be considered for COVID Oximetry @home (CO@h)
  • The eligibility criteria are as follows:
    • each patient must be diagnosed with COVID-19 (either clinically or with a test) and be symptomatic
    • the patient must then be EITHER:
      • aged 65 years or older, OR
      • under 65, and at higher risk from COVID-19. Clinical judgement applies considering individual risk factors such as pregnancy, learning disability, caring responsibilities, and/or deprivation
  • CO@h is a self-monitored and self-escalated pathway, with optional check-in calls for some patients. Patients are provided with a pulse oximeter, a supporting pack including instructions on self-monitoring, and clear guidance on safety netting and escalation
  • For those patients in whom a self-monitored pathway is not clinically deemed to be sufficient, a referral to local CO@h services providing proactive telephone calls to support patient monitoring should be considered
  • Please note that all patients who are eligible for COVID-19 therapies should also be considered for CO@h monitoring, as they are in high-risk groups.

COVID-19 treatments

  • As per Algorithm 1, the highest risk patients with mild-to-moderate symptoms should be considered for treatment with new antibody and antiviral treatments if they are within 5 days of symptom onset
  • Two types of COVID-19 treatments are available:
    • neutralising monoclonal antibodies usually given by infusion or injection in a local hospital or health centre
    • oral antiviral treatment—currently molnupiravir (Lagevrio) in capsule form that can be taken at home
  • Patients who are eligible for these treatments should be referred to COVID-19 medicines delivery units (CMDUs)
  • Patients who are not eligible for COVID-19 treatments could be eligible for the PANORAMIC trial.

COVID-19 medicines delivery units

  • The majority of patients at highest risk from COVID-19 (listed in Table 1) will be identified centrally. These patients have been sent a letter to notify them that they are eligible to receive COVID-19 treatments in the event of a positive polymerase chain reaction (PCR) test. If they receive a positive COVID-19 PCR result, they will usually be contacted via regional CMDUs within 24 hours of their positive test result
  • A small number of these highest risk patients may not be contacted by CMDUs due to data mismatch. In the notification letter, patients have been advised to contact their GP practice or 111 if they test positive and have not been contacted by CMDU within 24 hours. GPs and 111 can refer these patients to CMDUs via e-Referral Service (eRS) (or using the locally agreed process if one has been put in place and communicated in your local area)
  • In addition, consultants and specialist teams have also been asked to write to patients who cannot be identified centrally (for example, newly diagnosed or those receiving chemotherapy or radiotherapy in the last 6 months). These patients will need to ask for referral and ask NHS Test and Trace for a PCR test to keep at home
  • GPs may also encounter patients who are in the highest risk group but have not been identified as such via the central matching process (such as if they are homeless or are not registered with a GP). These patients should also be referred to CMDUs via eRS (or using the locally agreed process if one has been put in place and communicated in your local area)
  • Proactive outreach by GP practices is not expected
    • therefore, if you are assessing a patient who is at highest risk (as listed in Table 1), has not been contacted by a CMDU, and meets the criteria for referral below, you should refer to a CMDU
    • if your area is using eRS to refer to CMDUs, the NHS has asked commissioners that their CMDU services are listed in the infectious diseases specialty, under a non-specific (‘not otherwise specified’) clinic type, but to include in the service name the words ‘COVID-19 medicine delivery unit (CMDU)’. Some services may have been established with the service name ‘COVID MABS delivery unit (CMDU)
  • Referral criteria for CMDU:
    • positive PCR test within 5 days, AND
    • onset of COVID-19 symptoms within 5 days AND
    • patient is a member of the highest-risk cohort (listed in Table 1)
    • NOT requiring hospitalisation or oxygen for COVID-19
    • NOT under 12 years old
    • NOT a child weighing less than 40 kg
  • The main message for everyone is that vaccination is key and is still the mainstay of protecting people against COVID-19.

COVID-19 treatment pathway—overview for GPs

Algorithm 2: COVID-19 treatment pathway—overview for GPs/111

Overview for GPs 111

For information on the PANORAMIC study and additional resources, refer to the full guideline.

 

Full guideline:

NHS England. Assessment, monitoring and management of symptomatic COVID-19 patients in the community. Available at: england.nhs.uk/coronavirus/publication/assessment-monitoring-and-management-of-symptomatic-covid-19-patients-in-the-community/

Contains public sector information licensed under the Open Government Licence v3.0.

Published date: 06 January 2022.

Credit:

Lead image: Konstantin Yuganov/stock.adobe.com