NICE Guidelines on Managing Rheumatologic Conditions During COVID-19 Pandemic Save

On April 3rd, the National Institute for Health and Care Excellence (NICE) in the UK, published a rapid guideline for managing children and adults with rheumatological autoimmune, inflammatory and metabolic bone disorders during the COVID-19 pandemic, while protecting staff from infection. The guideline was intended to aid health care practitioners, health and care staff involved in planning and delivering services, and commissioners.

The recommendations were drawn from existing national and international guidelines and policies, advice from specialists from across the UK.  As these recommendations were developed to deal with a rapidly evolving situation; much is based on evidence and expert opinion. NICE intends to update the recommendations as the knowledge and experience evolves.

A NICE guidance addresses several key areas that are summarized below.

I. Communicating with patients and minimising risk

• In communicating with patients it is important to minimize face-to-face contact (cutting non-essential face-to-face consultations; offering telephone or video consultations; contacting patients via text message or email)
• Use alternative ways to deliver medicines, such as postal services, NHS volunteers or drive through pick-up points
• Expand community-based blood monitoring services, where possible
• Contact the rheumatology team about any rheumatological medicines issues or if their condition worsens 

II. For Patients Not Known to have COVID-19

• For patients who must attend the rheumatology clinic, ask them to come without a family member or carer if they can, to reduce the risk of contracting or spreading the infection in the course of their transport.
• If they must come to hospital, tell patients not to arrive early or come only when summoned that staff are ready to see them (wait outside the building, in their car, etc)
• Schedule patients to avoid overlap and contact with other patients
• Delivering treatments or dispense medications promptly

III. Patients Known or Suspected to have COVID-19

• Patients with known or suspected COVID‑19 need to follow appropriate UK government guidance on infection prevention and control. This includes recommendations on patient transfers, and options for outpatient settings
• Patients on hydroxychloroquine and sulfasalazine should continue these meds
• Do not suddenly stop prednisolone
• only give corticosteroid injections if the patient has significant disease activity and there are no alternatives
• Temporarily stop other disease-modifying antirheumatic drugs, JAK inhibitors and biological therapies, and tell them to contact their rheumatology department for advice on when to restart treatment.  

IV.  Treatment Considerations

• Be aware that patients on immunosuppressant treatments may have atypical presentations of COVID‑19
• 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 changes in dosage, route of administration, etc.
• Non-steroidal anti-inflammatory drugs: NSAIDs do not need to be stopped when used to treat a long-term condition such as rheumatoid arthritis
• Corticosteroids: advise patients taking prednisolone that it should not be stopped suddenly. Only use methylprednisolone for treating major organ flares
• Biological treatments: Assess whether patients having intravenous treatment can be switched to subcutaneous treatment (for example, tocilizumab, abatacept, belimumab). Assess whether patients having infliximab can be switched to an alternative subcutaneous tumour necrosis factor inhibitor. Assess whether maintenance treatment with rituximab can be reduced to 1 pulse or the duration between treatments increased
• Immunoglobulins: Assess whether the frequency of intravenous immunoglobulins can be reduced in patients attending day-care services in line with NHS England's clinical guide on the management of patients requiring immunoglobulin treatment
• Bisphosphonates and denosumab: Do not postpone treatment with denosumab.  Treatment with zoledronate can be postponed for up to 6 months.
• Treatments for digital ulcer disease: Ensure that patients having intravenous prostaglandins (for example, iloprost, epoprostenol) have had the maximum dose of sildenafil. Assess whether they can be switched to bosentan.

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. 

Modifications to Usual Care  

• Maintain a robust on-call service for cross-consultant referrals that is available all the time, teaming up with other NHS trusts if necessary.
• In tertiary centres, maintain specialised rheumatology networks and virtual multidisciplinary team meetings to discuss the management of complex disorders and to ratify high-cost drug use.
• Primary care SHOULD 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.
• For urgent new referrals from primary care for suspected inflammatory arthritis, suspected autoimmune connective tissue diseases and vasculitis (including giant cell arteritis), offer a phone or virtual consultation followed by a face-to-face appointment after asking about COVID‑19 symptoms.
• For urgent follow ups (such as for ongoing and new flares, and for treatment adjustment after monitoring), think about using phone or virtual consultations followed by a face-to-face appointment, if needed, after asking about COVID‑19 symptoms.
• For in-patients: maintain rheumatology ward cover, and an out-of-hours on-call service to: provide advice on immunosuppressive drugs' carry out assessments of rheumatological and COVID‑19 disease status and enable early discharge.

Healthcare Professionals

• All healthcare workers assessing and caring for patients who have known or suspected COVID‑19 should follow UK government guidance for infection prevention and control. This contains information on using personal protective equipment (PPE), including visual and quick guides for putting on and taking off PPE.
• Make provisions to provide care by enabling telephone or video consultations, and attendance at virtual multidisciplinary team meetings
• Identifying patients who are suitable for remote monitoring and follow up, and those who are vulnerable and need support
• Support staff to keep in touch as much as possible, to support their mental wellbeing
• Provide all staff with visible leadership and supportive messaging, to maintain morale.