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Overview

The purpose of this guideline is to maximise the safety of children and adults with rheumatological autoimmune, inflammatory, and metabolic bone disorders during the COVID-19 pandemic, while protecting staff from infection. It also enables services to make the best use of NHS resources.

This Guidelines summary only covers key recommendations for primary care. For the complete set of recommendations, see the full guideline.

Communicating with patients and minimising risk

  • Communicate with patients and support their mental wellbeing, signposting to charities and support groups (such as ARMA, which has a list of relevant organisations, and NHS Volunteer Responders) where available, to help alleviate any anxiety and fear they may have about COVID-19
  • Minimise face-to-face contact by:
    • cutting non-essential face-to-face consultations
    • offering telephone or video consultations
    • contacting patients via text message or email
    • making use of departmental pages on local NHS trust websites
    • using rheumatology department advice services, including out-of-hours services, and thinking about a shared approach with other NHS trusts
    • using alternative ways to deliver medicines, such as postal services, NHS volunteers or drive through pick-up points
    • expanding community-based blood monitoring services, where possible
  • Advise patients to contact:
    • NHS 111 by phone or via the website for advice on COVID-19
    • their rheumatology team about any rheumatological medicines issues or if their condition worsens (or NHS 111 or primary care services, if this is not possible)
  • Tell patients who still need to attend services to follow relevant parts of government advice on social distancing (this differs across the UK) or UK government guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19.

Patients not known to have COVID-19

  • If patients have to attend the rheumatology department, ask them to come without a family member or carer if they can, to reduce the risk of contracting or spreading the infection. Encourage them to use their own transport, and to travel alone to the department whenever possible. Ask that children are accompanied by only 1 parent or carer.

Patients known or suspected to have COVID-19

  • Be aware that patients having immunosuppressant treatments may have atypical presentations of COVID-19. For example, 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. This includes information on testing and isolating patients
  • When patients with known or suspected COVID-19 have been identified, follow appropriate UK government guidance on infection prevention and control. This includes recommendations on patient transfers, and options for outpatient settings.

Treatment considerations

Treatment decisions based on risk

  • 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. Use Tables 1 and 2 and take into account the following in the context of COVID-19:
    • whether the patient has had a COVID-19 vaccination
    • their condition (see Table 1; be aware that individual patients may have additional risk factors that could place them in a higher risk group)
    • the medicines they are having (see Table 2); use of immunosuppressant treatments may be more important in determining risk than the person’s underlying condition
    • any additional risk factors:
      • high treatment doses
      • use of multiple immunosuppressant drugs
      • active disease
      • co-morbidities or complications, such as interstitial lung disease or pulmonary fibrosis, pulmonary hypertension or pulmonary arterial hypertension, respiratory muscle weakness, asthma, chronic obstructive pulmonary disease, cardiac involvement, glomerulonephritis or renal impairment, neutropenia, liver disease, diabetes mellitus, ischaemic heart disease, or hypertension
      • pregnancy
      • older age (older than 70) 
  • Be aware that immunosuppressant drugs may not always be listed on primary care records because they are prescribed in secondary care
  • Be aware that people with autoimmune connective tissue diseases or vasculitis may have complications such as respiratory muscle weakness, interstitial lung disease, pulmonary hypertension, or heart involvement that may increase the risks associated with COVID-19.

Table 1: Conditions that pose a potential risk above that in the general population

ConditionRisk grading

Systemic lupus erythematosus

Intermediate to very high

Systemic sclerosis scleroderma

Intermediate to very high

Myositis, polymyositis, dermatomyositis, antisynthetase syndrome

Intermediate to very high

Primary Sjögren’s syndrome

Intermediate or high

Overlap connective tissue disease (CTD)

Intermediate or high

CTD-related interstitial lung disease, rheumatoid arthritis (RA)-related interstitial lung disease

High or very high

CTD-related pulmonary hypertension, RA-related pulmonary hypertension

High or very high

Relapsing polychondritis

Intermediate to very high

Antineutrophil cytoplasmic antibody-associated vasculitis, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, or microscopic polyangiitis

Intermediate to very high

Aortitis

Intermediate to very high

Takayasu arteritis

Intermediate to very high

Giant cell arteritis or temporal arteritis

Intermediate to very high

Behçet’s disease

Intermediate to very high

Polyarteritis nodosa

Intermediate to very high

Vasculitis (other)

Intermediate to very high

Adult-onset Still’s disease

Intermediate to very high

Autoinflammatory syndromes

Intermediate to very high

Immunoglobulin G4-related disease

Intermediate to very high

Rheumatoid arthritis

Intermediate or high

Psoriatic arthritis

Intermediate or high

Ankylosing spondylitis or axial spondyloarthritis

Intermediate or high

Juvenile idiopathic arthritis

Intermediate or high

Polymyalgia rheumatic

Intermediate

Severe osteogenesis (previously types 3 and 4) imperfecta (if mobility is restricted or chest wall shape or lung capacity are affected)

High or very high

Fibrodysplasia ossificans progressive

High or very high

Severe kyphosis or scoliosis from rare bone diseases, for example, hypophosphatasia, type 1 osteogenesis imperfecta, Hajdu Cheney

High or very high

Table 2: Immunosuppressant medicines and techniques used for maintenance treatment that could increase a patient’s risk

Medicine or techniqueRisk grading

Prednisolone 10 mg per day (or equivalent) or more for more than 4 weeks with one other immunosuppressant

High to very high

Prednisolone 20 mg (0.5 mg/kg in children weighing less than 40 kg) or more per day (or equivalent) for more than 4 weeks

Very high

Prednisolone 10–19 mg (or equivalent) per day for more than 4 weeks monotherapy

High

Azathioprine

Intermediate to high

Ciclosporin

Intermediate to high

Cyclophosphamide

Very high

Hydroxychloroquine

Low

Leflunomide

Intermediate to high

Methotrexate

Intermediate to high

Mycophenolate mofetil

Intermediate to high

Sirolimus

Intermediate to high

Sulfasalazine

Low

Tacrolimus

Intermediate to high

Abatacept

High

Adalimumab

Intermediate to high

Anakinra

Intermediate

Apremilast

Low

Belimumab

High

Certolizumab pegol

Intermediate to high

Etanercept

Intermediate to high

Golimumab

Intermediate to high

Infliximab

Intermediate to high

Ixekizumab

Intermediate to high

Rituximab

High

Sarilumab

Intermediate to high

Secukinumab

Intermediate to high

Tocilizumab

Intermediate to high

Ustekinumab

Intermediate to high

Baricitinib

Intermediate

Tofacitinib

Intermediate

Upadicitinib

Intermediate

Apheresis

Very high

Human stem cell transplant

Very high

Non-steroidal anti-inflammatory drugs

  • Advise patients taking a non-steroidal anti-inflammatory drug for a long-term condition such as rheumatoid arthritis that it does not need to be stopped.

Corticosteroids

For recommendations on the use of biologic treatments, immunoglobins, bisphosphonates and denosumab, and treatments for digital ulcer disease in the context of COVID-19, refer to the full guideline.

Drug monitoring

  • Assess with each patient whether it is safe to increase the time interval between blood tests for drug monitoring, particularly if 3‑monthly blood tests have been stable for more than 2 years
  • Patients starting a new disease-modifying antirheumatic drug should follow recommended blood monitoring guidelines. When this is not possible, they should contact the relevant specialist for advice
  • Think about pooling drug monitoring resources between local organisations.

Modifications to usual care

Primary care and the community

  • Use rheumatology department advice lines, run by staff with appropriate knowledge, to provide professional advice to primary care and community colleagues about all patients. If available, use an electronic advice and guidance service for GPs
  • The ARMA specialist guidance on urgent and emergency musculoskeletal conditions requiring onward referral supports primary and community care practitioners in recognising serious pathology that needs emergency or urgent referral to secondary care. When prioritising urgent and emergency musculoskeletal referrals to secondary care, refer to Table 3 in the full guideline
  • In musculoskeletal services, prioritise rehabilitation for patients who have had recent elective surgery or a fracture, and for those with acute or complex needs (including carers). Focus on enabling self-management in line with NHS England’s guide on COVID-19 prioritisation within community health services

For recommendations on modifications to usual care in outpatient, day care, and inpatient settings, refer to the full guideline.

 

© NICE 2021. COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders. Available from: nice.org.uk/ng167. 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: 03 April 2020.

Last updated: 31 March 2021.