Rheumatology

24th March 2020

In order to reduce the risk of spreading infection and to help the NHS cope with the sickest patients, we have implemented the following measures.

  1. Patients, relatives and carers reporting any symptoms of any acute respiratory infection, should not attend healthcare premises, unless specifically told to do so by your specialist team.  If you have a fever or a continuous cough, or breathing difficulties, you may have a COVID-19 infection and should follow separate public health advice (see below)
  2. Your specialist Rheumatology team remains responsible for monitoring your rheumatic disease.  They will decide whether you need a face-to-face consultation, but most patients will now be offered an alternative using telephone, video (e.g. Skype, Facetime, What’sApp) or text messaging. Urgent patients will be prioritised and the frequency of follow-up visits may be reduced
  3. If you still need a face-to-face consultation, then your team will be able to arrange this but you might be seen in a different site or area than you are used to. If there is any risk that you may have a COVID-19 infection then the team may need to wear some personal protective equipment (PPE), such as a mask, apron and gloves to reduce the risks of transmission
  4. If you normally receive a seasonal influenza vaccine, then we recommend this is up to date, as well as vaccinations against shingles and pneumococcus. Your general practitioner can advise on this
  5. If you are over the age of 70 OR if you are taking treatments (see list below) which suppress immunity then you are considered at high risk of more severe infection with COVID-19.  In this case, you should:
    1. Self-isolate to reduce unnecessary social contact
    2. Report promptly any symptoms of infection. If you feel unwell with any infection, or if you develop symptoms of COVID-19 then you will probably need to stop your immunosuppressive treatments until you have recovered. There are some anti-rheumatic medications that can continue despite infection (sulfasalazine and hydroxychloroquine) and note that steroids such as prednisolone should not be stopped suddenly. Contact us as soon as you can for advice
    3. There is no evidence that you should stop taking immunosuppressive medications in order to prevent you getting COVID-19
  6. Some immunosuppressive drugs stop working very quickly (e.g. baricitinib) while others last for many months (e.g. rituximab). During the pandemic your team may recommend using shorter acting drugs, delaying starting new immunosuppressive treatments or using smaller doses than usual to help protect your immunity
  7. Patients on immunosuppressive therapies may not exhibit typical symptoms or signs of infection e.g. reduced fever, white cell response or CRP, so always tell your doctors what medication you normally take, especially if they do not know you

This advice is based on several sources and expert opinion, and should not be regarded as comprehensive. As new evidence emerges you can expect advice may change.

Appendix

Immunosuppressive medications include:
Apremilast, azathioprine, baricitinib, ciclosporin, cyclophosphamide, leflunomide, methotrexate, mycophenolate, tacrolimus, tofacitinib, biologic therapies (including etanercept, adalimumab, certolizumab, infliximab, tocilizumab, abatacept, anakinra) and rituximab. 

Note: Hydroxychloroquine and sulfasalazine are not considered immunosuppressive.

NSAIDs
The effect of drugs like ibuprofen and naproxen on COVID-19 infection is not clear.  There is insufficient evidence to recommend that patients stop such medicines routinely.

Research
We do not know whether patients may acquire COVID-19 more than once, but this should be known soon. Urgent research on candidate vaccines and drug therapies is underway internationally. Please refer to the latest version of the information link below to ensure up to date advice.

Yasmeen Ahmed, PhD, FRCP
Consultant Rheumatologist and Clinical Lead
Peter Maddison Rheumatology Centre, Llandudno Hospital

Mark Garton, MD, FRCP, MSc Public Health
Consultant Physician and Rheumatologist
Wrexham Maelor Hospital
Visiting Professor at Glyndwr University

Detailed advice and guidance for Rheumatology patients is available from the British Society of Rheumatologists.