Rheumatology

5th January 2021

Dear Rheumatology patients

I sincerely hope you and your family are staying safe and limiting your contact with others during this second wave and lockdown period.

To protect yourself and others, please wash your hands with soap and water for 20 seconds, cough into a tissue and discard immediately, avoid touching your face and avoid contact with anyone who is unwell. Keep your distance when out and about.

This advice applies to adults with rheumatic disease and is current from 5th January 2021.

The risk to children and young people is very small and therefore the previous shielding advice given in the first lockdown is no longer valid for this patient group and they should be guided by their specialist centre.

According to the government’s guidance on clinically extremely vulnerable people, adults on immunosuppression therapies sufficient to significantly increase risk of infection are considered clinically extremely vulnerable (CEV). CEV people should have previously received a letter from the NHS and/or their GP explaining what this means for them in the summer 2020. They will also (if they haven’t already) receive a further letter explaining the new guidance during this second lockdown.

Due to the high volume of calls/emails we are receiving regarding covid-19 and anti-rheumatic drugs and reduced staffing levels, we are not reliably able to answer individual calls or respond to emails with regard to medication and covid-19. I hope the following information is helpful in explaining current advice for our patients.

Please note, we are unable to assist in government shielding letters. You may need to discuss this with your GP.

For patients on the following drugs: methotrexate, leflunomide, azathioprine, cyclophosphamide, cyclosporin, mycophenolate, tacrolimus and all biologic treatments (including anti TNF, anti-IL1, anti-IL6, Abatacept, Rituximab, JAK inhibitors) patients are divided into a  “shielding” group, moderate risk group advising social distancing  and self-isolation at patient discretion if no other risk factors (work from home/avoid contact with groups of people/touching surfaces other people may have touched etc) and a low risk group advising standard social distancing.  See stratification table below.

Hydroxychloroquine and/or sulfasalazine treatment do not confer increased risk

 

Risk stratification guide	Patients to shield (clinically extremely vulnerable (CEV))	Moderate risk – patients to self-isolate or maintain social distance at their discretion	Patients to maintain social distance
Immunosuppressive medication	∙Corticosteroid dose of ≥20mg (0.5mg/kg)prednisolone (or equivalent) per day for more than four weeks ∙Cyclophosphamide at any dose orally or within last six months IV ∙Corticosteroid dose of ≥5mg prednisolone (or equivalent) per day for more than four weeks plus at least one other immunosuppressive medication, biologic/monoclonal or small molecule immunosuppressant (eg JAK inhibitors) ∙Any two agents among immunosuppressive medications, biologics/monoclonals or small molecule immunosuppressants with any co-morbidity	∙Well-controlled patients with minimal disease activity and no co-morbidities on single agent broad spectrum immunosuppressive medication, biologic/monoclonal or small molecule immunosuppressant ∙Well-controlled patients with minimal disease activity and no co-morbidities on single agent broad spectrum immunosuppressive medication plus Sulphasalazine and/or hydroxychloroquine ∙Well-controlled patients with minimal disease activity and no co-morbidities on a single agent broad spectrum immunosuppressive medication at standard dose (eg Methotrexate up to 25mg per week) plus single biologic (eg anti-TNF or JAKi)	∙Single agent 5-ASA medications(eg mesalazine) ∙Single agent 6-mercaptopurine ∙Only inhaled or rectally administered immunosuppressant medication ∙Hydroxychloroquine ∙Sulphasalazine

 Broadly, there are four risk groups:

• (1) Over-70s, regardless of any medical conditions.
• (2) Under-70s who have an underlying health condition - in other words, adults who are advised to have the flu jab every year on medical grounds. This group includes people who have:

o    Long-term respiratory or lung disease, like asthma or chronic obstructive pulmonary disease (COPD); Long-term heart disease, like heart failure ; Long-term kidney disease; Long-term liver disease, like hepatitis; Diabetes; Long-term neurological conditions like Parkinson's disease, motor neurone disease, multiple sclerosis (MS), cerebral palsy, or a learning disability; A weakened immune system, either as a result of a medical condition like HIV or AIDS, or as a result of medications like corticosteroids or chemotherapy; A body mass index (BMI) of 40 or above (being severely obese); Sickle disease (not trait).

• (3) Pregnant women.
• (4) Complex Medical Disorders. This fourth group are at the highest risk of severe illness from coronavirus and are likely to take even more extreme measures to protect themselves. They are now classed in the 'shielded' category.

General advice

(1)  If you are well, do NOT stop taking your anti-rheumatic medication unless advised to do so by your Rheumatology team. By stopping your medication you may be more likely to flare which could put you at increased risk of contracting any infection.

(2) Do NOT stop steroid treatment suddenly. If you are infected with COVID-19, you may require more steroid treatment than usual. Please contact your GP for advice.  

(3) If you are unwell, as with any other infection, omit your anti-rheumatic medication for 1-2 weeks and restart once the infection has been treated

(4) If you suspect you have coronavirus infection, please follow national guidance and contact NHS 111 or its online service for further advice and  https://www.gov.uk/get-coronavirus-test to book a test on-line

(5) Most patients with follow up appointments booked in the following weeks will receive a telephone consultation. New patients and patients with active inflammatory and connective tissue diseases will be able to attend for face to face appointments

(6) Do NOT attend the hospital unless it is an urgent problem.

The following web-links provide further, detailed COVID-19 advice:

Advice specifically for patients from Versus Arthritis :  https://www.versusarthritis.org/news/2020/april/coronavirus-covid-19-and-arthritis-where-to-go-for-information/

 Advice from the British Society of Rheumatology for patients and doctors: https://www.rheumatology.org.uk/practice-quality/covid-19-guidance

 Advice from the Government:

(a)  Lockdown guidance: https://www.gov.uk/guidance/national-lockdown-stay-at-home

 (b) Clinically vulnerable groups: https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

 (c) Shielding Support Website: https://www.gov.uk/coronavirus-shielding-support

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COVID-19 Vaccination

The Pfizer/BioNTech and Oxford AstraZeneca vaccine COVID-19 vaccine have been authorised for use by the Medicines and Healthcare products Regulatory Agency (MHRA) and are currently being rolled out across the UK.

The Pfizer/BioNTech vaccine is not a live vaccine, and people who take medicines to suppress the immune system can have this vaccine. People on these types of drugs are on the priority list for vaccination that has been produced by the Joint Committee on Vaccination and Immunisation (JCVI).

The Oxford AstraZeneca vaccine has now also been licensed in the UK. Again this is suitable for people who are on drugs that suppress the immune system.

Community vaccination programmes are currently being planned and patients should wait to be contacted with an invitation to attend for vaccination.

The following web-links provide further vaccination advice:

Advice specifically for patients: https://www.versusarthritis.org/covid-19-updates/vaccines-for-covid-19-your-questions-answered/

The British Society of Rheumatology (BSR)  guidance for patients and doctors: https://www.rheumatology.org.uk/practice-quality/covid-19-guidance

 Vaccination Eligibility groups:  https://www.gov.uk/search/all?keywords=covid+19+vaccination&order=relevance

 With all best wishes for the coming months.

Dr Kelsey M Jordan

Clinical Lead, Rheumatology