Guidance
4 Treatment considerations
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:
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dosage
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route of administration
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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.
4.3 If a patient is having or going to have immunosuppressive treatments, follow the advice on COVID-19 vaccination in the green book. Additional resources include the ARMA principles for COVID-19 vaccination in musculoskeletal and rheumatology for clinicians and the Speciality Pharmacy Service information on using COVID-19 vaccines in patients taking immunosuppressive medicines. [amended 31 March 2021]
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:
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whether the patient has had a COVID‑19 vaccination
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their condition (see table 1; be aware that individual patients may have additional risk factors that could place them in a higher risk group)
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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
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any additional risk factors:
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high treatment doses
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use of multiple immunosuppressant drugs
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active disease
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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
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pregnancy
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older age (older than 70). [amended 31 March 2021]
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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]
|
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 |
|
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 |
|
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.