COVID-19 guideline on rheumatological autoimmune, inflammatory, and metabolic bone disorders

No comments

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

Discuss with each patient the benefits of treatment compared with the risks of becoming infected. Think about whether any changes to their medicines are needed during the current pandemic, including:
- dosage
- route of administration
- mode of action
  
  Encourage and support shared care, by helping patients to carry out elements of their own care.
Think about how treatment changes will be delivered and what resources are available. Be aware that some homecare drug delivery services are not accepting new referrals, in which case the department would need to organise this
If a patient is having or going to have immunosuppressive treatments, follow the advice on COVID-19 vaccination in the Green Book. Additional resources include the ARMA principles for COVID-19 vaccination in musculoskeletal and rheumatology for clinicians and the Speciality Pharmacy Service information on using COVID-19 vaccines in patients taking immunosuppressive medicines.

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

Condition	Risk 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 technique	Risk 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

Advise patients taking prednisolone that it should not be stopped suddenly
Use oral corticosteroids. Only use an intravenous or intramuscular corticosteroid (such as methylprednisolone) when benefits outweigh the risks. Refer to the British Society for Rheumatology’s clinical guide on the management of patients with musculoskeletal and rheumatic conditions on 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 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.