for those patients taking DMARD, Biologic and/or Steroid medication during the COVID-19 outbreak.
British Society for Rheumatology has published several updates over the last few days to help us safely manage out-patient group during the Covid-19 outbreak, and Gastrology has provided an update regarding medicine monitoring, included in the table below.
Rheumatology and Gastrology Guidance on the following medicines
| Drug Name | Changes to monitoring during COVID-19 |
| Methotrexate | 2 weeks after start of treatment 6 weeks after start of treatment 3 months after start of treatment Then once every 6 months (providing patient not also co-prescribed Leflunamide when monitoring should not exceed once every 2 months) If dose increase – needs blood test at 2,6,12 weeks then 6 monthly |
| Sulfasalazine | 2 weeks after start of treatment 6 weeks after start of treatment 3 months after start of treatment Then once every 6 months for 1 year If dose increase – needs blood test at 2,6,12 weeks then 6 monthly. |
| Leflunamide | 2 weeks after start of treatment 6 weeks after start of treatment 3 months after start of treatment Then once every 6 months ( providing patient not also co-prescribed Methotrexate when monitoring should not exceed once every 2 months). If dose increase – needs blood test at 2,6,12 weeks then 6 monthly. |
| Azathioprine | 2 weeks after start of treatment 6 weeks after start of treatment 3 months after start of treatment Then once every 6 months for 1 year If dose increase – needs blood test at 2,6,12 weeks then 6 monthly. |
| Penicillamine | 2 weeks after start of treatment 6 weeks after start of treatment 3 months after start of treatment Then once every 6 months for 1 year If dose increase – needs blood test at 2,6,12 weeks then 6 monthly. |
| Mesalazine | 3 months after start of treatment 6 monthly for 2 years After 2 years – blood monitoring can be discontinued if results are normal and doses stable. |
| Mercaptopurine | 2 weeks after start of treatment 6 weeks after start of treatment 3 months after start of treatment Then once every 6 months If dose increase – needs blood tests at 2 weeks, 6 weeks, 12 weeks then 6 monthly |
The key factors outline as a follow:
- Patients requiring SHIELDING i.e. highest risk patients requiring to stay at home for 12 weeks
This information can be found in a table form here:
There is also a very helpful scoring system for patients to easily identify those in the highest risk group.
Summary of those requiring Shielding
- Prednisolone >20mg/day for >4 weeks
- Oral or IV cyclophosphamide in the last 6 months
- Prednisolone (5mg/day or more) plus one other immunosuppressive *medication
- Two or more immunosuppressive medication plus a co-morbidity**
*Sulphasalazine and hydroxychloroquine as not classed as immunosuppressive medications for this guidance. See BSR guidance above for detailed list of immunosuppressive medications.
**Includes age>70, history of diabetes, ischaemic heart disease, hypertension, pre-existing lung disease, renal impairment.
Patients who have rheumatoid arthritis (RA) or CTD-related interstitial lung disease (ILD) are at additional risk and may need to be placed in the shielding category. All patients with pulmonary hypertension are placed in the shielding category.
- DMARDs, Biologics and steroids
This guidance HAS NOT changed. Patients should remain on their current treatment and only stop if they develop symptoms of infection.
Stopping medication risk a flare and possible steroid use – both of which are significantly immunosuppressive.
Sulphasalazine and hydroxychloroquine do not need to be stopped if patients develop in infection.
We will only start patients on DMARD and Biologics medication if absolutely necessary during this time.
3 Blood monitoring for patients on DMARDs – modified for Covid 19 outbreak
Please see below modified NPT monitoring during Covid 19 outbreak.
4 Patient information
Versus Arthritis has published information on their website which patients can be signposted to:
EULAR has published guidance and a very helpful video giving advice to patients regarding the Covid outbreak:
https://www.eular.org/eular_guidance_for_patients_covid19_outbreak.cfm
5. Out-patient appointments
- All out-patient appointments have or will be cancelled except for small number of urgent appointments. Some telephone and video appointments will continue. This will be reviewed regularly in line with government guidance.
- There will be very limited physiotherapy and occupational therapy appointments over the next few months.
- Patients should be advised to ensure their details including telephone numbers are updated. Please ask patients to remove any blocks on 0800 numbers.
6. Steroids and NSAID
There has been a lot of discussion in the media regarding the use of NSAID. NHS England has released a statement.). At present there is no firm evidence of NSAIDs increasing risk of acquiring Covid-19 and NICE has been asked to review. In the interim the advice is to use paracetamol for Covid-19 related fever and patients on existing NSAID should have their treatment continued.
We are aware that some organisation (e.g. Faculty of Pain Medicine) are avoiding steroid joint injections at present. We would recommended that steroids in all forms (oral, intra-muscular and intra-articualar are immunuppressive are careful consideration need to be given regarding risk/benefit on a case by case basis. The default position will be no steroids unless absolutely necessary.
7. Advice
Health professionals and patients can continue to ask for advice via the usual routes for their departments. There will be a limitation in availability of rheumatology professionals when hospital staff will be prioritising in-patient care. (Contact details for Rheumatology sites to follow).
- Rheumatology MCN Clinical Lead Dr Gillian Roberts
To help delay the spread of coronavirus, protect patients and reduce pressure on NHS services at this challenging time, the Rheumatology specialty have agreed to change the monitoring requirements for a number of medications. If blood test results fall outwith accepted parameters then further monitoring may be required. These guidelines will be reviewed by 1st July 2020 or at the end of the COVID outbreak whichever comes sooner.
GGC Rheumatology MCN
