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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):

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

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

Current advice from the MHRA is that until there is clear, definitive evidence of these medicines being safe and effective for the treatment of COVID-19, they should only be used for this purpose within a clinical trial.

MHRA (26 June 2020): Chloroquine and Hydroxychloroquine not licensed for coronavirus (COVID-19) treatment

  • Guidance on the monitoring of patients taking clozapine (Zaponex®) and carrying out the associated mandatory blood tests in the context of the current COVID-19 pandemic have been developed and shared by ZTAS® and Leyden Delta BV.
  • There is currently no data suggesting that clozapine patients should not continue to take their clozapine if they are suspected to have contracted COVID-19. Although specific information is lacking, the advice refers to their standard information with regards to clozapine use in patients with influenza or other airway infections.

ZTAS and Leyden Delta BV (12 March 2020): COVID-19 infection and blood monitoring via ZTAS

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

For specific advice on how patients should be managed during this pandemic, BSR refer to the NICE published COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders.

NICE (31 March 2021): COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders

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.

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

Similar advice can be found on the National Rheumatoid Arthritis Society (NRAS) website along with a link to frequently asked questions. The Society are also hosting regular Q&A sessions to address concerns and questions from the public around Rheumatoid Arthritis and COVID-19.

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 National Institute for Health and Care Excellence (NICE) has published a COVID-19 rapid guideline relating to rheumatological autoimmune, inflammatory and metabolic bone disorders. The advice given is to ‘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'.

NICE (31 March 2021): COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders

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

In light of the current unprecedented impact of COVID-19, the UK Department of Health and Social Care (DHSC) has relaxed its previous position to accommodate the reuse of medicines under limited specific circumstances as outlined in this guidance.

The following standard operating procedure (SOP) supports timely access to essential end of life (EoL) medicines during the COVID-19 pandemic for patients who are being cared for in a care home or hospice setting, by offering a framework to run a safe and effective medicines reuse scheme that is in the best interest of patients.

NHS Wales (Version 1, April 2020): Novel coronavirus (COVID-19) standard operating procedure – Running an END OF LIFE medicines reuse scheme in a care home or hospice setting

Immunosuppressant continuation during the COVID-19 pandemic

Rheumatology

NICE has published a Coronavirus (COVID-19) rapid guideline on rheumatological autoimmune, inflammatory and metabolic bone disorders.

NICE (31 March 2021): COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders

The British Society for Rheumatology (BSR) recommends 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 starting or switching a patient to a new medication is being planned, this may now need to be reviewed. Patients on long-term glucocorticoids (steroids, prednisolone) should not stop these abruptly.

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. For those on glucocorticoids, the expectation is that treatment should not be stopped abruptly and advice should be sought from their treating team.

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

Transplant patients

The British Transplantation Society advises that levels of immunosuppression should be reviewed but generalised immunosuppression reduction that may jeopardise organ function is not recommended.

British Transplantation Society (24 August 2021): Coronavirus: COVID-19 ­- Information for transplant professionals – 23rd Edition

Inflammatory Bowel Disease (IBD)

The British Society of Gastroenterology advises patients not to stop or reduce their medication without discussing with the IBD Team, due to risk of flare leading to a need for steroids or other additional immunosuppression or hospitalisation. Therapy-specific advice for use of immune-suppressant in IBD is available on the British Society of Gastroenterology website.

British Society for Gastroenterology (30 March 2021): BSG expanded consensus advice for the management of IBD during the COVID-19 pandemic

Neurology Patients

Guidance from the Association of British Neurologists (ABN) states that many people with neuro-immunological conditions receive immunotherapies and some of these immunotherapies might increase the severity of a COVID-19 infection. Stable patients without symptoms of COVID-19 infection with neurological conditions should not stop or alter their medication without prior discussion with their neurology team. Further specific advice is included for:

  • azathioprine, mycophenolate mofetil, methotrexate with or without prednisolone
  • infliximab/rituximab/ocrelizumab
  • multiple sclerosis disease-modifying therapies.

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

There is separate guidance on the use of disease-modifying therapies in multiple sclerosis in response to the threat of a coronavirus epidemic.

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 the above link does not work, the document can be found on the ABN COVID-19 Guidance page)

Advice on corticosteroids for patients with musculoskeletal and rheumatic conditions

The British Society for Rheumatology states that, as is current practice, injections must not be undertaken in individuals with active infections. In the current situation, the potential therefore arises to do harm to those who may be incubating or later develop COVID-19.

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

A joint guideline from the British Society of Rheumatology, the British Orthopaedic Association, the British Association of Spine Surgeons, the Faculty of Pain Medicine of the Royal College of Anaesthetists, the Royal College of General Practitioners, the British Pain Society, the Chartered Society of Physiotherapy and the British Society of Interventional Radiology has also been developed, providing further guidance on the use of steroid medication in patients with musculoskeletal and rheumatic conditions. Key advice from the guideline includes:

  • Don’t stop current steroids but taper their dose if possible and if it is clinically safe to do so, in line with usual practice.
  • Think before starting steroids in the current pandemic. Use the lowest possible dose of oral steroids for the shortest period of time.
  • Starting oral prednisolone at more than 5 mg per day for more than a month could move a patient into the shielding group.
  • Starting oral prednisolone at more than 20 mg per day (or greater than 0.5 mg/kg/day for children) for more than a month will move a patient into the shielding group.
  • Only give a steroid injection if a patient has significant disease activity and/or intrusive and persisting symptoms, and there are no appropriate alternatives.

BSR, BOA, BASS, RCGP, BSIR, FPM, BPS and CSP (16 June 2020): Management of patients with musculoskeletal and rheumatic conditions who: are on corticosteroids; require initiation of oral/IV corticosteroids; or require a corticosteroid injection

Guidance on the use of lithium during the current COVID-19 pandemic has been developed and shared by the South London and Maudsley NHS Foundation Trust.

The narrow therapeutic range of lithium means that patients potentially infected with COVID-19 require extra considerations within their ongoing treatment plan. This advice refers to some further actions that may need to be considered in this patient group.

South London and Maudsley NHS Foundation Trust (25 March 2020): COVID-19 and lithium

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

Administration of medication via nebulisation is in a category of procedures not considered to represent significant infectious risk in the COVID guidance for infection prevention and control guidance issued by NHS England, Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland and the UK Health Security Agency as official guidance.

DHSC, PHW, PHA Northern Ireland, HPS and PHE (latest version): Infection prevention and control for seasonal respiratory infections in health and care settings (including SARS-CoV-2) for winter 2021 to 2022

 

For further information refer to ‘COVID-19: infection prevention and control (IPC)’.

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)

Welsh Government have published guidance advising that vitamin D supplements should be taken during the winter to support general health (particularly bone and muscle health). This is particularly important this year, as many will have been indoors more than usual.

Welsh Government (4 November 2020): Vitamin D advice for everyone: coronavirus

NICE has also produced a rapid guideline covering 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

ONE WALES DECISION DURING THE COVID-19 PANDEMIC: Abiraterone (ZYTIGA®) and enzalutamide (Xtandi®) are supported for the treatment of hormone-sensitive prostate cancer during the COVID-19 pandemic. Apalutamide (Erleada®) is no longer supported for this indication.

Date of most recent re-assessment: December 2020.

Using the agreed starting and stopping criteria, abiraterone or enzalutamide can be made available for the treatment of high-risk locally advanced and metastatic hormone-sensitive prostate cancer during the COVID-19 pandemic. Enzalutamide is not licensed to treat these indications and abiraterone is not licensed to treat low-risk metastatic disease or high-risk locally advanced disease. Please refer to the One Wales decision for full advice.

‘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

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued temporary advice for initiation of valproate in female patients and for annual review and pregnancy testing to support adherence to pregnancy prevention requirements during the pandemic when face-to-face appointments may not be possible.

MHRA (May 6 2020): Valproate pregnancy prevention programme: temporary advice for management during coronavirus (COVID-19)

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)

Current advice from the Royal College of General Practitioners (RCGP) ‘Guidance on workload prioritisation during COVID-19’ includes vitamin B12 injections in the ‘amber’ and ‘red’ categories:

  • Amber category – continue if capacity allows and if appropriate for your patient population
    Vitamin B12 injections for post bariatric surgery patients - consider teaching appropriate patients to self-administer and ensure frequency is not more than 12 weekly. Review whether oral supplementation with cyanocobalamin tablets would be appropriate.
  • Red category – lower priority routine work which could be postponed in the event of a high prevalence of COVID-19 in your patient population, aiming to revisit once the pandemic ends, ensuring recall dates are updated where possible.
    Consider teaching appropriate patients to self-administer vitamin B12 (hydroxocobalamin 1mg) injections and ensure frequency is not more than 12 weekly. Review whether oral supplementation with cyanocobalamin would be appropriate if asymptomatic with a dietary deficiency (BMJ, 2019 – Investigating vitamin B12 deficiency [direct link]).

RCGP (10 April 2020): RCGP Guidance on workload prioritisation during COVID-19

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’.

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