4 Treatment considerations

4.1 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:

  • dosage

  • route of administration

  • mode of action.

    Encourage and support shared care, by helping patients to carry out elements of their own care.

4.2 Think about how treatment changes will be delivered and what resources are available. Be aware that some homecare drug delivery services are not accepting new referrals, in which case the department would need to organise this.

Treatment decisions based on risk

4.4 When deciding whether to start a new treatment with a drug that affects the immune response, discuss the risks and benefits with the patient, or their parents or carers. Use tables 1 and 2 and take into account the following in the context of COVID‑19:

  • whether the patient has had a COVID‑19 vaccination

  • their condition (see table 1; be aware that individual patients may have additional risk factors that could place them in a higher risk group)

  • the medicines they are having (see table 2); use of immunosuppressant treatments may be more important in determining risk than the person's underlying condition

  • any additional risk factors:

    • high treatment doses

    • use of multiple immunosuppressant drugs

    • active disease

    • comorbidities or complications, such as interstitial lung disease or pulmonary fibrosis, pulmonary hypertension or pulmonary arterial hypertension, respiratory muscle weakness, asthma, chronic obstructive pulmonary disease, cardiac involvement, glomerulonephritis or renal impairment, neutropenia, liver disease, diabetes mellitus, ischaemic heart disease or hypertension

    • pregnancy

    • older age (older than 70). [amended 31 March 2021]

4.5 Be aware that immunosuppressant drugs may not always be listed on primary care records because they are prescribed in secondary care. [amended 31 March 2021]

4.6 Be aware that people with autoimmune connective tissue diseases or vasculitis may have complications such as respiratory muscle weakness, interstitial lung disease, pulmonary hypertension or heart involvement that may increase the risks associated with COVID-19. [amended 31 March 2021]

Table 1 Conditions that pose a potential risk above that in the general population [amended 31 March 2021]

Condition

Risk grading

Systemic lupus erythematosus

Intermediate to very high

Systemic sclerosis scleroderma

Intermediate to very high

Myositis, polymyositis, dermatomyositis, antisynthetase syndrome

Intermediate to very high

Primary Sjögren's syndrome

Intermediate or high

Overlap connective tissue disease (CTD)

Intermediate or high

CTD-related interstitial lung disease, RA-related interstitial lung disease

High or very high

CTD-related pulmonary hypertension, RA-related pulmonary hypertension

High or very high

Relapsing polychondritis

Intermediate to very high

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) or microscopic polyangiitis

Intermediate to very high

Aortitis

Intermediate to very high

Takayasu arteritis

Intermediate to very high

Giant cell arteritis (GCA) or temporal arteritis

Intermediate to very high

Behçet's disease

Intermediate to very high

Polyarteritis nodosa

Intermediate to very high

Vasculitis (other)

Intermediate to very high

Adult-onset Still's disease

Intermediate to very high

Autoinflammatory syndromes

Intermediate to very high

Immunoglobulin G4-related disease (IgG4-RD)

Intermediate to very high

Rheumatoid arthritis

Intermediate or high

Psoriatic arthritis

Intermediate or high

Ankylosing spondylitis or axial spondyloarthritis

Intermediate or high

Juvenile idiopathic arthritis (JIA)

Intermediate or high

Polymyalgia rheumatic (PMR)

Intermediate

Severe osteogenesis (previously types 3 and 4) imperfecta (if mobility is restricted or chest wall shape or lung capacity are affected)

High or very high

Fibrodysplasia ossificans progressive

High or very high

Severe kyphosis or scoliosis from rare bone diseases, for example, hypophosphatasia, type 1 osteogenesis imperfecta, Hajdu Cheney

High or very high

Table 2 Immunosuppressant medicines and techniques used for maintenance treatment that could increase a patient's risk [amended 31 March 2021]

Medicine or technique

Risk grading

Prednisolone 10 mg per day (or equivalent) or more for more than 4 weeks with 1 other immunosuppressant

High to very high

Prednisolone 20 mg (0.5 mg/kg in children weighing less than 40 kg) or more per day (or equivalent) for more than 4 weeks

Very high

Prednisolone 10 mg to 19 mg (or equivalent) per day for more than 4 weeks monotherapy

High

Azathioprine

Intermediate to high

Ciclosporin

Intermediate to high

Cyclophosphamide

Very high

Hydroxychloroquine

Low

Leflunomide

Intermediate to high

Methotrexate

Intermediate to high

Mycophenolate mofetil

Intermediate to high

Sirolimus

Intermediate to high

Sulfasalazine

Low

Tacrolimus

Intermediate to high

Abatacept

High

Adalimumab

Intermediate to high

Anakinra

Intermediate

Apremilast

Low

Belimumab

High

Certolizumab pegol

Intermediate to high

Etanercept

Intermediate to high

Golimumab

Intermediate to high

Infliximab

Intermediate to high

Ixekizumab

Intermediate to high

Rituximab

High

Sarilumab

Intermediate to high

Secukinumab

Intermediate to high

Tocilizumab

Intermediate to high

Ustekinumab

Intermediate to high

Baricitinib

Intermediate

Tofacitinib

Intermediate

Upadicitinib

Intermediate

Techniques

-

Apheresis

Very high

Human stem cell transplant

Very high

Non-steroidal anti-inflammatory drugs

4.7 Advise patients taking a non-steroidal anti-inflammatory drug for a long-term condition such as rheumatoid arthritis that it does not need to be stopped.

Corticosteroids

4.8 Advise patients taking prednisolone that it should not be stopped suddenly.

4.9 Use oral corticosteroids. Only use an intravenous or intramuscular corticosteroid (such as methylprednisolone) when benefits outweigh the risks. Refer to the British Society for Rheumatology's clinical guide on the management of patients with musculoskeletal and rheumatic conditions on corticosteroids. [amended 31 March 2021]

Biological treatments

4.10 Assess whether patients having intravenous treatment can be switched to the same treatment in subcutaneous form. If this is not possible, discuss with the patient an alternative subcutaneous treatment. [amended 24 April 2020]

4.11 Assess whether maintenance treatment with rituximab can be reduced to 1 pulse or the duration between treatments increased. Also assess whether patients with stable disease can stop maintenance treatment with rituximab or be switched to an alternative immunosuppressant. Discuss the possible outcomes of the different options with the patient before coming to a shared decision. [amended 31 March 2021]

Immunoglobulins

4.12 Assess whether the frequency of intravenous immunoglobulins can be reduced in patients attending day-care services.

Bisphosphonates and denosumab

4.13 Do not postpone treatment with denosumab.

4.14 Treatment with zoledronate can be postponed for up to 6 months.

Treatments for digital ulcer disease

4.15 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.