Specific areas of interest

• Whilst some media reports and publications have suggested that treatment with ACE inhibitors or ARBs might worsen COVID-19 infection, there is no evidence from clinical or epidemiological studies to support this.
• The Medicines and Healthcare products Regulatory Agency (MHRA) has stated: ‘If you are taking angiotensin converting enzyme inhibitors (ACE inhibitors or ACE-i) or angiotensin receptor blockers (ARBs) to treat high blood pressure, it is vitally important you continue your usual treatment.’

MHRA (27 March 2020): Coronavirus (COVID-19) and high blood pressure medication

In order to manage additional demand for anaesthesia and intensive care medicines, the Royal College of Anaesthetists and its partners, working with NHS England and NHS Improvement, have published the following important guidance (Note: some of the following guidance was archived on 1 October 2020):

• Guidance on potential changes to anaesthetic drug usage and administration during pandemic emergency pressures (Archived)
• Guidance on adaptations to standard UK critical care medication prescribing and administration practices during pandemic emergency pressures (Archived)
• Frequently asked questions for patients (Archived)
• Anaesthetic guidance relating to Tier 3 Alert of supplies of Atracurium, Cisatracurium and Rocuronium (Archived)
• Critical care guidance relating to the Tier 3 Alert of supplies of Atracurium, Cisatracurium and Rocuronium (Archived)
• COVID-19 potential anaesthetic drug list

Further information can be found via the following link.
Royal College of Anaesthetists, the Faculty of Intensive Care Medicine, the Intensive Care Society and the Association of Anaesthetists (17 April 2020): COVID-19 guidance hub

• Note that from 31/12/2021, no new content will be published on this website. Although this guidance was correct at the stated time of publication, readers should be aware some content may not reflect the latest authoritative guidance. Content relevant to anaesthetic and critical care management during the COVID-19 pandemic will continue to be published on the websites of these four organisations:
• RCOA- www.rcoa.ac.uk
• Association- www.anaesthetists.org
• ICS- www.ics.ac.uk
• FICM- www.ficm.ac.uk

The Medicines and Healthcare products Regulatory Agency (MHRA), which is the UK regulator for medicines and medical devices, has issued advice to healthcare professionals and patients on the monitoring of patients taking blood thinning tablets (also known as anticoagulants) during the COVID-19 pandemic.

MHRA (13 October 2020): Warfarin and other blood thinners – reminder on safe use during COVID-19 pandemic

A National Patient Safety Alert has been issued on the risk of inappropriate anticoagulation of patients with a mechanical heart valve.

NHS England (14 July 2021): National Patient Safety Alert – Inappropriate anticoagulation of patients with a mechanical heart valve

The British Geriatrics Society has produced a guideline on managing delirium in confirmed and suspected cases of COVID-19.  A series of recommendations are made, including recommendations on the use of pharmacological treatment options.

British Geriatrics Society (25 March 2020): Coronavirus: Managing delirium in confirmed and suspected cases

In the context of the current COVID-19 pandemic, Diabetes UK have put together some helpful information for people living with diabetes and their families. This includes specific advice if patients have COVID-19 symptoms, and advice on managing diabetes whilst having to stay at home.

Diabetes UK (updated regularly): Coronavirus and diabetes

Currently, the British Society for Rheumatology (BSR) advise all patients, including those aged 16 years and under, should continue to take their medication unless directed otherwise by their rheumatology team or GP. If there are plans to start or switch a patient to a new medication this may now need to be reviewed. If patients develop symptoms of any infection, established practice should be followed and immunosuppressive therapy paused for the duration of the infection and until they feel well, in consultation with their rheumatology team.

BSR (latest version is available here): COVID-19 Guidance

The COVID-19 guidance published by BSR provides advice and signposts for a comprehensive list of frequently asked questions covering: patient management, advice for health professionals considered at risk, information on COVID-19 trials and where to find further general advice regarding the pandemic.

This advice is for clinicians. The website states that patients looking for further information on whether their condition places them in a higher-risk category, or about precautions they should take, are advised to speak to their clinical team, who are best placed to answer specific questions.

The British Society of Gastroenterology (BSG) has established a UK-wide COVID-19 working group and advises all patients to continue to attend for infusions of biologics. The following resource includes a list of the top ten tips for all patients with inflammatory bowel disease (IBD), as well as therapy-specific considerations which include: veldolizumab, ustekinumab and anti-TNF therapy.

BSG (30 March 2021): Expanded consensus advice for the management of IBD during COVID-19 pandemic

Drug Monitoring

In order to reduce hospital and GP patient attendance during the Covid-19 pandemic, it is recommended that blood test monitoring schedules are relaxed. This is only for stable cDMARD patients whose blood tests have been satisfactory up until now. Currently, there is limited information nationally on a definitive interval.

The British Society of Gastroenterology (BSG) provides general considerations regarding inflammatory bowel disease medications (IBD). The list includes identifying an experienced/senior person to reduce any therapy-associated monitoring blood tests to minimum safe frequency.

BSG (30 March 2021): Expanded consensus advice for the management of IBD during COVID-19 pandemic

The Liverpool Drug Interaction Group (based at the University of Liverpool), in collaboration with the University Hospital of Basel (Switzerland) and Radboud UMC (Netherlands) have produced various materials in PDF format to aid the use of experimental agents in the treatment of COVID-19.

These resources are available at www.covid19-druginteractions.org/

The Royal College of General Practitioners (RCGP) has developed a series of resources on delivering end of life care in the context of the COVID-19 pandemic, including a summary of the changes in death certification and a guide to community palliative, end of life and bereavement care.

RCGP Learning (latest version is available here): End of life care

Immunosuppressant continuation during the COVID-19 pandemic

British Society for Rheumatology (latest version is available here): COVID-19 guidance

British Transplantation Society (latest guidance): Coronavirus: COVID-19 ­- Information for transplant professionals

British Society for Gastroenterology (latest guidance): BSG expanded consensus advice for the management of IBD during the COVID-19 pandemic

Association of British Neurologists (9 April 2020): Guidance on COVID-19 for people with neurological conditions, their doctors and carers (If this link does not work, the document can be found on the ABN COVID-19 Guidance page)

Association of British Neurologists (5 November 2020): Guidance on the use of disease-modifying therapies in multiple sclerosis in response to the COVID-19 pandemic (If this link does not work, the document can be found on the ABN COVID-19 Guidance page)

British Society for Rheumatology (latest version is available here): COVID-19 guidance

BSR, BOA, BASS, RCGP, BSIR, FPM, BPS and CSP (published 20 Nov 2020): Management of patients with musculoskeletal and rheumatic conditions who: are on corticosteroids; require initiation of oral/IV corticosteroids; or require a corticosteroid injection

The MHRA has issued temporary guidance for specialists and patients about oral isotretinoin, alitretinoin and acitretin and the use of remote consultations for monitoring safety requirements.

MHRA (22 June 2021): Temporary advice for management of oral retinoid medicines during the COVID-19 pandemic

The MHRA has since issued an associated Drug Safety Update.

MHRA (7 July 2021): Oral retinoid medicines (isotretinoin▼, alitretinoin▼, and acitretin▼): temporary monitoring advice during coronavirus (COVID-19) pandemic

The Commission of Human Medicines (CHM) Expert Working Group on coronavirus (COVID-19) has concluded that there is currently insufficient evidence to establish a link between use of ibuprofen, or other NSAIDs, and susceptibility to contracting COVID-19 or the worsening of its symptoms.

Patients can take paracetamol or ibuprofen when self-medicating for symptoms of COVID-19, such as fever and headache, and should follow NHS advice if they have any questions or if symptoms get worse.

CHM Expert Working Group on COVID-19 (14 April 2020): Commission on Human Medicines advice on ibuprofen and coronavirus

MHRA, National Medical Director NHS England and NHS Improvement, Chief Executive of NICE (14 April 2020): Ibuprofen and coronavirus (COVID-19)

Chief Pharmaceutical Officer for Wales (15 April 2020): Ibuprofen and coronavirus (COVID-19)

NICE have produced a rapid guideline which covers the use of vitamin D in the context of COVID-19; for adults, young people and children in hospitals and community settings.

NICE (17 December 2020): COVID-19 rapid guideline: Vitamin D

‘Rescue packs’ containing oral steroids and antibiotics are sometimes prescribed for patients with COPD or asthma, to keep at home and use as part of a personal asthma or COPD management plan when experiencing an exacerbation.

Rescue packs should only be used in those people who have previously been prescribed them to manage exacerbations as part of their agreed COPD or asthma management plan.

Inappropriate requests for unnecessary medication could lead to supply problems for patients who genuinely require these medicines, and divert valuable time and resources from patients most in need.

The British Thoracic Society (BTS) has stated that oral steroids are not currently prescribed as part of the treatment for COVID-19.

If a patient with asthma develops symptoms and signs of an exacerbation they should follow their personalised action plan and start a course of oral steroids if clinically indicated.

BTS (26 November 2020): Advice for healthcare professionals treating people with asthma (adults) in relation to Covid-19

BTS have stated that there is no evidence to use or not to use oral or inhaled corticosteroids outside usual guidance in COPD patients with COVID-19.

Antibiotics should only be issued if suspicion of secondary bacterial infection.

BTS (29 March 2020): COPD and COVID-19 for healthcare professionals

A number of information sources provide advice on managing patients requiring Vitamin B12 (hydroxocobalamin 1 mg) injections during the current COVID-19 pandemic.

The British Society for Haematology (BSH) ‘Guidance on Vitamin B12 replacement during the COVID-19 pandemic’ recommends the following:

Non-dietary vitamin B12 deficiency

Eg: Pernicious anaemia, prior gastrectomy, bariatric surgery, achlorhydria, pancreatic insufficiency, short bowel syndrome, bacterial overgrowth, inflammatory bowel diseases.

• The need for intramuscular (IM) hydroxocobalamin 1 mg injections should be discussed with each patient individually.
• Screening questions for COVID-19 should be asked before patients attend their GP practice.
• Alternatives to attending the GP practice should be considered, for example administration by district nurses.
• As an alternative, oral cyanocobalamin can be offered at a dose of 1 mg/day until regular IM hydroxocobalamin injections can be resumed, i.e. once GP practices are able to do so safely, aiming to have the shortest possible break from regular injections.
• Patients should be advised to monitor their symptoms and should contact their GP if they begin to experience neurological or neuropsychiatric symptoms.
• Patients who already self-administer IM hydroxocobalamin should continue to do so. BSH does not recommend switching patients to self-administration at this current time due to likely difficulties with instruction.

Vitamin B12 deficiency thought to be diet related

• An alternative to twice-yearly hydroxocobalamin 1 mg injections is to prescribe oral cyanocobalamin 50 – 150 mcg, daily between meals.
• BSH recommends reassessing serum B12 prior to recommencing IM injections.
• Some patients may be vitamin B12 replete and therefore may be able to stop taking vitamin B12 supplements for up to a year.
• However, patients on vegetarian and vegan diets should continue to take oral supplements.
• Dietary advice should be given to all patients.

BSH (1 May 2020): Guidance on Vitamin B12 replacement during the COVID-19 pandemic
(If the above link does not work, you can find the guidance on the BSH COVID-19 Updates page)

Advice from the Royal College of General Practitioners (RCGP) ‘Guidance on workload prioritisation during COVID-19’ includes vitamin B12 injections in the ‘Activities to consider pausing, postponing or deprioritising’ category.

RCGP (21 December 2021): COVID-19 workload prioritisation guide for general practice during the accelerated booster vaccination campaign (England).

Summary

• Practices should discuss the most appropriate course of action with their patients, depending on individual need and circumstances and according to advice for that patient group.
• Where it has been agreed that the patient should attend the practice for an injection or to be taught to self-administer, the patient should be phoned on the day of the appointment to establish whether they are showing signs of COVID-19.
• Where patients are taught to self-administer, provide appropriate needles and syringes as these are not available on WP10. Ensure that a sharps bin is prescribed with the hydroxocobalamin injection and inform the patient how collection of the bin can be arranged when it is full or no longer required.
• Ensure those patients who are delaying treatment are followed up and recalled when the current restrictions are lifted.
• Patients who are vegan or who have proven vitamin B12 deficiency of dietary origin may be prescribed cyanocobalamin, ensuring that the prescription is endorsed ‘SLS’.
• Where patients are willing to purchase oral cyanocobalamin from the pharmacy, inform them that it is likely it will have to be ordered in, and may take a few days. Alternatively, the advice from the Association of UK Dieticians lists some options available from health food shops. Ensure that the patient is aware of the appropriate strength and dose to take.

N.B. Oral supplementation
Within Wales, oral cyanocobalamin falls under the ‘Selected List Scheme’, i.e. medicines that may only be ordered in certain circumstances. Drug Tariff requirements state that oral cyanocobalamin can only be prescribed to a patient who is vegan or who has proven vitamin B12 deficiency of dietary origin for the purpose of treatment of prevention of vitamin B12 deficiency. The prescriber must endorse the prescription with the reference ‘SLS’.