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

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

• 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

• 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
• 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 delivery
    
    Encourage and support shared care, by helping patients to carry out elements of their own care
• When deciding about treatments, use Tables 1 and 2 in NHS England’s clinical guide on the management of rheumatology patients. This includes a list of patients who are at risk of infection because of the medicines they are taking and information about risk grading
• 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

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

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
• Prioritise urgent and emergency musculoskeletal referrals to secondary care in line with NHS England’s clinical guide on urgent and emergency musculoskeletal conditions requiring onward referral
• 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