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Rheumatological autoimmune and inflammatory disorders: rapid guideline summary


11 May, 2020  

The purpose of NG167 is to maximise the safety of both adults and children with rheumatological autoimmune, inflammatory and metabolic bone disorders during the COVID-19 pandemic.

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

  • Do not postpone denosumab
  • Postpone treatment with zoledronate for up to six months

Treating digital ulcer disease

  • Ensure that patients having intravenous prostaglandins have the maximum dose of sildenafil and assess whether they can be changed to bosentan.

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.