4 Treatment considerations

4.1 Be aware that patients having immunosuppressant treatments may have atypical presentations of COVID‑19. For example, patients taking prednisolone may not develop a fever, and those taking interleukin‑6 inhibitors may not develop a rise in C‑reactive protein.

4.2 If a patient not previously known or suspected to have COVID‑19 shows symptoms at presentation, follow UK government guidance on investigation and initial clinical management of possible cases. This includes information on testing and isolating patients.

4.3 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 delivery.

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

4.4 When deciding about treatments, use tables 1 and 2 in NHS England's clinical guide on the management of rheumatology patients. This includes a list of patients who are at risk of infection because of the medicines they are taking and information about risk grading.

4.5 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.

Non-steroidal anti-inflammatory drugs

4.6 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

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

4.8 Only use methylprednisolone for treating major organ flares. Think about using oral corticosteroids and refer to NHS England's clinical guide on the management of patients with musculoskeletal and rheumatic conditions on corticosteroids.

Biological treatments

4.9 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]

4.10 Assess whether maintenance treatment with rituximab can be reduced to 1 pulse or the duration between treatments increased.

Immunoglobulins

4.11 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

4.12 Do not postpone treatment with denosumab.

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

Treatments for digital ulcer disease

4.14 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.