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18th May 2020
The guideline offers advice on what should be either stopped or started during the pandemic though healthcare staff need to use the guidance in conjunction with any other professional guidelines, standards and relevant laws in line with advice on decision-making when using NICE guidance.
Patient communication and minimising infection risk
NG176 discusses the importance of communicating with patients, their families and carers to support their mental wellbeing during the COVID-19 pandemic to alleviate any anxieties or concerns they might have about the virus. The guideline suggests signposting patients to relevant sources of information such as Kidney Care UK coronavirus guidance, the National Kidney Federation, any local kidney patient organisations and the UK government guidance mental health and wellbeing aspects of COVID-19.
NG176 advises staff to remind patients who have received a letter from the government to follow advice on shielding and that their risk may change over time based on advice from either primary care teams or their specialist kidney units.
For those with booked appointments, it is recommended that they do not to stop any current medicines unless advised to do so and to maintain a current list of treatments if they require treatment for COVID-19. Where patients have been advised to self-isolate, they should follow the government stay at home advice for anyone with possible coronavirus infection.
Consultations
NG176 advises on the need to minimise face-to-face consultations and to make use of either telephone or video instead or to contact patients via email or text messaging and to issue electronic rather than paper prescriptions. It is also recommended that teams explore alternative delivery routes for prescriptions and medicines such as pharmacy delivery services, via the post, using NHS volunteers or drive through medicine pick-up points.
Patients should be advised to contact both their renal teams and the NHS111 online coronavirus service if they believe that they are infected with COVID-19, but if seriously ill to contact emergency services.
In cases where patients are required to attend for blood tests, they should attempt to reduce the risk of contracting COVID-19 by following the relevant advice on social distancing, attending appointments alone or with only one other and to avoid public transport if possible but if this is unavoidable to wear face covering. If face-to-face appointments are necessary, staff should minimise the time patients spend in the waiting area through careful scheduling of appointments, discouraging early attendance and by asking patients to remain in their transport vehicle until they receive a text message informing them that they are ready to be seen. NG176 strongly recommends a “clean route” through the hospital and that treatments and prescriptions are delivered and dispensed rapidly.
Managing the underlying condition in patients known or suspected of having COVID-19
Where a patient is known or suspected of having COVID-19, NG176 advises staff to follow the UK government guidance on infection prevention and control. However, if COVID-19 is detected at a later stage and the patient was not initially isolated, the NG176 suggests following the UK government guidance on the management of exposed healthcare workers and patients.
In contrast, if a patient not known to be infected displays COVID-19 symptoms when first presenting, NG176 advises staff to follow the UK government guidance on investigation and initial clinical management of possible cases.
Managing chronic kidney disease (CKD)
Changes to usual care
NG176 recommends specialist centres modify usual care to reduce patient exposure to COVID-19 and to make best use of available resources. Any modification to a patient’s treatment should be undertaken by a multi-disciplinary team and in light of clinical circumstances and any relevant preferences and the reasoning behind the changes fully documented. The risks and benefits of any changes to treatment or care should be fully discussed with the patient.
Medicines
NG176 recommends that patients continue with all current medicines unless or until, advised to do so by a member of their specialist team and this includes patients with COVID-19 infection. The guideline notes advice from the Renal Association UK that ACE inhibitors and angiotensin receptor blockers can be continued. Moreover, NG176 signposts healthcare staff to advice from the Renal Association on the use of immunosuppressive therapy for autoimmune conditions.
It is advised in NG176 that staff review current medication taken by those with CKD, irrespective of COVID-19 status to determine whether any of their treatments have an adverse effect on renal function.
Monitoring of those with CKD
For those who have recovered from COVID-19 infection, NG176 recommends that renal function is reassessed and that the urgency of this assessment is prioritised based on glomerular filtration rate (GFR) category, relevant comorbidities and clinical circumstances.
Where patients are deemed to be stable, the frequency of routine blood & urine tests can be reduced during the pandemic though any decisions should also consider if the patient’s CKD is progressive. Healthcare staff are advised to refer to the NICE guidance on chronic kidney disease for further information.
Self-monitoring and self-management (for example, blood pressure) with appropriate advice on safety netting is encouraged in NG176 as is a recommendation that patients should access their medical data via PatientView.
Specialist services
Referrals to renal services
NG176 recommends that non-urgent referrals to specialist services are delayed, for example, if the patient has only mild to moderate proteinuria and a stable GFR. However, the guidance makes clear that referrals should continue in cases where:
It is advisable to contact the renal team via telephone or virtually if there is any uncertainty about the need for an urgent outpatient referral.
Renal ultrasound
It is recommended that renal ultrasounds are delayed if the result is unlikely to lead to immediate changes to management. For instance:
However, NG176 suggest that patients SHOULD be referred for renal ultrasound where:
Hospital admission
NG176 advises that where staff are considering a hospital admission, they consider:
Advanced chronic kidney disease
For a patient starting dialysis, NG176 advises that staff continue to plan for this, for example, to perform procedures to create vascular and peritoneal access but to also consider whether it is safe to delay dialysis during the pandemic. It is also advised that referrals continue for patients who require transplantation but explain how some tests and assessments might be delayed due to the pandemic.
NG176 makes clear that all patients with advanced CKD are given the opportunity to participate in care planning and that all decisions and discussions are fully documented.
Healthcare workers
NG176 proposes that all NHS staff involved in all aspects of patient care (including receiving, assessing and caring) who have known/suspected COVID-19 infection, follow the UK government guidance for infection prevention and control.
In cases where staff are known/suspected of having COVID-19, or live in a household where another person is known/suspected of having the virus, they should self-isolate and only return to work in accordance with the UK government guidance on stay at home for households with possible COVID-19 infection.
If self-isolating staff are still able to work, recommended roles include undertaking telephone or video consultations and participation in virtual multidisciplinary meetings, helping to identify patients who can be monitored remotely and those who might require more support as well as performing any routine tasks which can be done remotely.
NG176 is available online and interested readers should check this version for further updates.
15th May 2020
The team analysed data on various parameters such as clinical signs and symptoms, imaging results, laboratory findings, demographic variables and medical history from 1590 patients to create a model. In total, 72 variables were included in the model although after further refinement this was reduced to only ten significant variables. These factors included chest X-ray abnormality, age, haemoptysis, dyspnoea and the number of comorbidities.
The accuracy of the model was assessed by the area under the receiver operator curve, which assesses its discriminatory power, that is, the ability of the model to correctly classify those with and without a risk of developing critical illness. Values between 0.80 and 0.90 are considered to be good and anything above 0.90 excellent; the new model had a value of 0.88.
The authors note that the ten variables would normally be readily available to clinicians and although based on Chinese patients, it is a potentially useful tool for screening patients admitted to hospital with COVID-19 infection.
Reference
Liang W, Liang H, Qu L. Development and validation of a clinical risk score to predict the occurrence of critical illness in hospitalized patients with Covid-19. JAMA Intern Med 2020; doi:10.1001/jamainternmed.2020.2033
The current results are based tests performed on 10,705 people in 5,276 households and exclude individuals in both hospital, care homes and other institutional settings. The data suggests that between 27 April and 10 May 2020, an average of 0.27% (95% confidence interval 0.17% – 0.41%) of the population, that is, 148,000 people in England were infected with COVID-19. However, the wide confidence intervals mean that the actual number can be anywhere between 94,000 and 222,000.
In terms of job roles, the analysis revealed how 1.33% of people in patient-facing roles such as doctors, nurses as well as social care roles (for example, social workers), tested positive compared with 0.22% of people not working in either of these sectors. Moreover, there was no difference in the proportions testing positive between different age categories which were grouped as 2–19, 20–49, 50–69 and 70 years and over.
The report notes that the uncertainty in their estimate will reduce as the number of people tested increases. Nevertheless, the data helps to provide an estimate of the rate of transmission (the R value) which will determine when and how the current lockdown measures are lifted.
Reference
Coronavirus (COVID-19) infection survey pilot: England, 10 May 2020. www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurvey/england10may2020 (accessed May 2020).
14th May 2020
The test called Elecsys®, developed by Roche, is an immunoassay for the detection of antibodies to SARS-CoV-2 in human serum and plasma and is a highly reliable marker of past infection.
The manufacturer’s information sheet cites a sensitivity of 100% (95% confidence intervals, CI, 88.1. – 100%) when used in patients 14 days after confirmed infection with COVID-19. It also has an overall specificity of 99.81% (95% CI 99.65 – 99.91%).
In the US, the FDA issued an Emergency Use Authorisation for Elecsys® on 3 May, which allows the test to be used during public health emergencies and, in the UK, the accuracy of the test has been confirmed by experts at PHE’s Porton Down facility. It is hoped that the test will enable the National Health Service to undertake hundreds of thousands of tests every week.
The purpose of antibody testing is to determine whether someone has been previously infected with coronavirus and is likely to be immune and so can return to work and thereby speed up the easing of the lockdown measures.
13th May 2020
Alarmingly, more than a third (36%) of patients with cirrhosis who developed the virus died. The rates of death in patients with liver disease are much higher than those observed in the general population, where studies predict between 3-4% of people who have tested positive for COVID-19 die.
The British Liver Trust is calling for the Government to include those with the most severe form of liver disease in the guidance for ‘extremely vulnerable’ people so that they follow the shielding advice and get access to support from their local authority.
The new findings have come from a collaborative international registry co-ordinated by the University of Oxford (UK) and the University of North Carolina (USA). Dr Thomas Marjot, who leads the team alongside Professor Ellie Barnes said, “Until now, we have known very little about the effects of coronavirus in patients with pre-existing liver disease. This multicentre study suggests that people with liver disease who develop COVID-19 have poor outcomes. The severity of underlying liver disease seems to predict poor outcome, with the most vulnerable patients being those with decompensated cirrhosis. We also show that contracting the virus may lead to a deterioration in liver function and therefore those coming into hospital with worsening symptoms of liver disease should be tested for coronavirus as soon as possible.”
The last month has seen the British Liver Trust’s nurse-led helpline receive 155% more calls than at the same time last year. Many of these are from people with decompensated cirrhosis who are confused about whether they should be shielding.
Professor Stephen Ryder, Medical Advisor to the British Liver Trust said, “Coronavirus is a new disease and we are still learning every day about the risks. As the UK begins to relax lockdown, this new data suggests that we need to make sure that everyone with liver disease continues to protect themselves from this virus by strictly following social distancing measures and that those with ‘decompensated liver disease’ follow the stricter shielding advice.
It’s also important to recognise that although these results are really worrying for liver disease patients they don’t apply to everyone. Doctors often only submit data to the registry for the most serious cases they see. Many other people who have contracted the virus at home, may have recovered and will not be in these records.”
The British Liver Trust is taking the issue of why decompensated liver disease patients are not included with the Government to seek further clarification. In the meantime, if patients are concerned about their own situation, they should contact their own liver specialist to obtain specific advice from them.
Pamela Healy, Chief Executive of the British Liver Trust said, “We urgently need the Government to ensure that these patients are shielding and are given the appropriate support. There is also a great deal of confusion confounded by the fact that the advice is different depending on whether you live in England, Scotland, Wales or Northern Ireland. From a patient perspective it would be really helpful if there was equity of advice and care across the nations.”
People with decompensated cirrhosis are already very ill with problems such as encephalopathy, ascites, jaundice and bleeding problems. Many of these patients have multiple complex problems including mental health issues, addiction, obesity and deprivation. They may not have family members who are able to support them in accessing food and medicines. It is therefore really important that these patients are provided with a letter so that they can access this support from their local authority.”
Shielding is different from social distancing as it involves staying at home at all times and avoiding all face to-face contact for at least twelve weeks, except from carers and healthcare workers who you must see as part of your medical care. The Trust has sought advice from senior liver clinicians and they have acknowledged that patients with decompensated cirrhosis are vulnerable and high risk. The British Liver Trust is therefore advising that all patients who have signs of decompensation (for example, jaundice, ascites, encephalopathy) or who have been hospitalised for liver disease to follow the shielding advice.
12th May 2020
Three primary care physicians, Dr Jonathan Leibowitz, Dr Robert Rothstein and Dr Aline Benjamin, have shared their insights and experiences.
Dr Leibowitz explained how the first patient was one of his own colleagues, Dr Aline Benjamin, another primary care physician in New York, who was suffering from COVID-19. After one dose of indomethacin, by the next morning her cough was “a million times better”, according to Dr Benjamin
Indomethacin is useful in the management of respiratory symptoms – relieving the pain on taking a deep breath and the incessant (and exhausting) coughing. The effect is evident after only one or two doses of 25-50mg. About 90% of patients respond to indomethacin treatment.
The feedback from patients has been very positive. “I have received many messages of thanks through my patient portal – we didn’t get that with hydroxychloroquine!” says Dr Leibowitz.
The beneficial effect appears to be specific to indomethacin rather than being a class effect with non-steroidal anti-inflammatory drugs (NSAIDs). Ibuprofen did not appear to have a beneficial effect on the cough.
Dr Leibowitz said, “If we had used indomethacin earlier, many patients would not have gone to the emergency room – and infected perhaps 100 other people in the process”.
In an effort to gain further insight into this important issue, three recently published reviews have analysed mortality data and all provide a consistent finding, namely that BAME patients appear more likely to die from infection with COVID-19. However, the finding of a higher mortality rate among BAME groups after viral infections is not new and was observed during the influenza A (H1N1) or ‘swine flu’ pandemic during 2009/2010 where those of non-white ethnicity experienced increased mortality compared to white populations (10.5/1000 vs 6/1000 general population).1 While the authors were unable to fully account for this disparity in death rate, other work revealed how increased socio-economic deprivation was linked to increased mortality from H1N1.2 But could these same factors account for the increased risk of death among BAME in the current pandemic? Two of the new reports suggest that it might.
The first report comes from the Office of National Statistics3 (ONS) and is based on deaths that occurred between 2 March 20202 and 10 April 2020 in England and Wales, outside of hospital in both confirmed and suspected cases of COVID-19. Although ethnicity is not recorded on the death certificate, the ONS linked deaths to the 2011 census, which allowed them to determine self-reported ethnicity and other demographic factors. Over the five-week period there were 12,805 deaths, of which 83.7% occurred in those of white ethnicity and 5.9% in Black patients and these figures were broadly similar to the deaths recorded by NHS England. The headline figure suggested that the risk of a COVID-19-related death was four-times higher in Black patients. However, the ONS report notes that this increased risk can be misleading in isolation as there may be confounding factors and any modelling of death rates has to make an adjustment for these factors to provide a more accurate assessment of the death risk based on BAME.
In modelling the death rates, the ONS used a binary logistic model in which the dependent variable, in this case death, has two possible values, that is, a BAME patient either died because of COVID-19 or they did not. Addition of other factors in the model which might have influenced death rate included socio-demographic issues, for example, where a person lived, the level of deprivation in the area, any associated health conditions reported in the 2011 census and living arrangements. The risk of death was expressed as an odds ratio (OR) and the results for different BAME groups in the adjusted model suggest, for example, that black patients are roughly 1.9-times more likely to die of COVID-10-related illnesses compared with white ethnic patients. The ONS report strongly suggests that differences COVID-19 mortality can be explained in a large part by socio-economic factors.
The second report from the institute for fiscal studies4 also suggests that socio-economic factors are a potentially important factor in explaining the differences in mortality. For instance, the report notes that the distribution of COVID-19 cases has not been evenly distributed throughout England and that this is one potential factor influencing mortality. For instance, 20% of confirmed cases have been in London and 60% of the overall Black population and 50% of the Bangladeshi population live in London. Another factor identified in the fiscal studies report was occupational exposure. The report identifies that those of Indian ethnicity make up over 14% of doctors and Black Africans account for 7% of nurses and that Indian and Black African men are 150% and 310% more likely to work in health and social care compared to white British men, which suggests that occupational risk is likely to be higher among BAME individuals. Other recognised factors include household structures and BAME patients are more likely to live in overcrowded accommodation. A third factor possible influencing excess death is health-related inequalities. It is known that 73% of Black people and 57% of Asians are overweight5 and that 44% of Pakistani men aged 55 years and older have type 2 diabetes.6 These comorbidities are likely to increase the risk of death once infected with COVID-19.
The third report is an analysis of the clinical characteristics of 520 hospitalised patients in an NHS trust and comes from a group at Imperial College London.7 The report found that although the crude OR for the risk of death of Black compared with White patients was not significant, (OR = 1.14, 95% CI 0.69 – 1.88), after adjusting for age and comorbidities, the result was border-line significant (OR = 1.72, 95% CI 0.98 – 3.02, p = 0.06). The authors called for further studies to investigate these associations on a larger scale.
In summary, and based on all of the currently available information, it seems certain that BAME patients are disproportionately affected by COVID-19 in line with the observations from the H1N1 viral pandemic and Public Health England (PHE) has launched a review into the topic. It is likely that no single factor is responsible but that several independent contributory underlying factors including socio-demographic, comorbidities and occupational-related exposure interact in a complex manner to raise mortality. Nevertheless, what is ultimately more important, is that the PHE review offers clarity on whether there are specific measures that can be undertaken by BAME to reduce their risk of infection.
References
11th May 2020
Patient communication and minimising infection risk
NG167 discusses the importance of communicating with patients, their families and carers to support their mental wellbeing during the COVID-19 pandemic and suggests signposting to the arthritis and musculoskeletal alliance (ARMA), which has information on COVID-19 to help alleviate any patient anxieties or fears about the virus.
NG167 suggests departments ask patients to contact NHS 111 for general information/advice on COVID-19 but their rheumatology department for specific advice on any rheumatological medicine-related issues or if their condition worsens. Alternatively, patients can contact NHS 111 or primary care services if this is not possible. Other suggestions include making use of departmental pages on local NHS trust websites and rheumatology department advice services, for example, out of hours and thinking about a shared approach with other trusts. NG167 recommends alternative routes for patients to obtain medicines including use of pharmacy deliveries, postal services, NHS volunteers or even drive-through pick-up points for medicines.
Patients not known to have COVID-19
Where patients need to attend rheumatology appointments, NG167 recommends they attend alone if possible and to use their own transport. Departments should seek to minimise exposure to infection while at the hospital by careful scheduling of appointments, discouraging patients from attending early and asking that they remain in their car until a text message is received alerting them when they are ready to be seen.
When at the hospital department, NG167 suggests that patients and staff follow the government advice on social distancing and shielding. Departments need to minimise both face-to-face contact for consultations and non-essential follow-up appointments and make greater use of telephone or video consultations, email or text messaging instead. Other suggested measures include a “clean route” for patients through the hospital to the department and that treatments are delivered promptly and prescriptions are dispensed rapidly. NG167 also asks that trusts consider expanding community-based blood monitoring services wherever possible.
Patients known or suspected of having COVID-19
Where patients are known or suspected of being infected with COVID-19, NG167 recommends that UK government guidance on infection prevention and control is followed. In cases where a patient is later diagnosed with COVID-19 and was not isolated from admission, departments are advised to follow the government guidance for health professionals.
Treatment considerations
NG167 reminds clinicians that patients taking immunosuppressant therapy may have atypical COVID-19 symptoms, for example, those taking prednisolone might not develop a fever and those using interleukin-6 inhibitors may not develop a rise in C-reactive protein.
Where patients start to develop possible COVID-19 symptoms, NG167 advises following the government guidance on investigation and initial management of possible cases. Staff should discuss with patients the balance of risks between continuing treatment and of becoming infected but also consider changing the route, dosage and mode of delivery of treatments during the pandemic. NG167 directs staff to the NHS England clinical guide on management of rheumatology patients. Because homecare drug delivery services are currently not accepting new referrals, staff need to explore ways in which patients can access treatments.
Specific treatments
DMARDs
Drugs such as hydroxychloroquine and sulfasalazine should be continued although patients are advised to stop any other disease-modifying antirheumatic drugs.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Where used long-term patients should continue.
Corticosteroids
Prednisolone should not be suddenly stopped and it is recommended that methylprednisolone can be used to treat major organ failure. Corticosteroid injections are only recommended where the patient has significant disease activity and where there are no alternatives. NG167 directs clinicians to NHS England’s clinical guideline on managing patients with musculoskeletal and rheumatic conditions on corticosteroids.
Biological treatments
These can be continued but staff should consider switching those receiving intravenous therapy to subcutaneous versions. Assess if patients using infliximab can be switched to alternative subcutaneous tumour necrosis factor inhibitor and whether maintenance rituximab can be reduced to 1 pulse or if the duration between treatments can be increased.
Immunoglobulins
Explore whether the frequency of treatment can be used in those attending day-care services.
Bisphosphonates and denosumab
Treating digital ulcer disease
Drug monitoring
NG167 asks that clinicians review whether it is safe to increase the interval between blood tests for drug monitoring, especially where 3-monthly blood results have been stable for more than two years. Patients starting a new disease modifying anti-rheumatic should continue to follow relevant blood monitoring guidance though specialist advice should be should if this is not possible. Wherever possible, NG167 suggests pooling drug monitoring resources between organisations.
Modification to usual care
NG167 directs clinical staff to NHS England’s guidance on management of rheumatology patients and the British Society for Rheumatology which provides a risk stratification guide for identifying those who require shielding. Only core services should be continued including advice lines, essential parental day cases, monitoring blood tests, on-call services and support for patients started on new injectables.
Primary care
Rheumatology advice lines should remain open to provide support to primary care and community colleagues. Any urgent referrals should be prioritised using the NHS England clinical guide on urgent and emergency musculoskeletal conditions. In addition, priority should be given to rehabilitation patients after recent elective surgery or for those with acute or complex needs but focusing on self-management based on NHS England’s guide.
Outpatients
For urgent new referrals, NG167 suggests phone or virtual consultations followed by a face-to-face contact after assessing for COVID-19 symptoms. For urgent follow-ups adopt the same process for referrals.
For day-care, NG167 advises that patients are prioritised based on their condition and for in-patients, it is suggested that ward cover and out-of-hours on-call services are maintained.
Healthcare workers
NG167 suggests how staff working with transplant patients and who need to self-isolate can continue to work, if possible. This might include video or telephone consultations, attending virtual multidisciplinary team meetings and roles such as identification of patients suitable for remote monitoring or the more vulnerable and routine work, for example, data entry. Furthermore, all staff with any aspect of direct patient contact where COVID-19 is suspected or known should follow the government guidance on infection and prevention control.
NG167 is available online and interested readers should check this version for further updates.
7th May 2020
The document was published in the Journal of the American College of Cardiology.
The COVID-19 pandemic has forced appropriate, but significant, restrictions on routine medical care, including invasive procedures to treat heart disease and diagnostic tests to diagnose heart disease. Many hospitals and practices have attempted to defer and replace these critical procedures with intensified triage and management of patients on waiting lists; however, many patients with untreated cardiovascular disease are at an increased risk of adverse outcomes, and delays in the treatment of patients with confirmed cardiovascular disease can be detrimental. Also, reduced access to diagnostic testing can lead to a high burden of undiagnosed cardiovascular disease that will further delay time to treatment.
The authors have outlined three areas that must be considered when reintroducing services, including:
“Unprecedented times call for unprecedented collaboration, and a collaborative approach will be essential to mitigate the ongoing morbidity and mortality associated with untreated cardiovascular disease,” said Athena Poppas, MD, FACC, ACC president and one of the authors on the document. “It is essential that we work together to ensure cardiovascular disease patients are safely cared for during this pandemic and that we don’t allow for a new crisis of undiagnosed, untreated or worsening cardiovascular disease to occur in the aftermath of this pandemic.”
The recommendations are published in Gastroenterology: AGA Institute Rapid Review of the GI and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19.
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