Rheumatology

Our rheumatology team manages adult patients (16+) with musculoskeletal complaints including inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis), connective tissue disease (SLE, scleroderma, myositis, Sjogrens syndrome), vasculitis and osteoporosis.

COVID-19 advice for rheumatology patients

Please help us help you by reading this information before contacting the rheumatology helpline number

We understand patients and their families with rheumatological diseases requiring immunosuppressant medications are concerned in light of the current coronavirus pandemic and wish to seek advice from their clinical teams.

The situation in the UK is changing rapidly with advice being updated regularly and we therefore recommend that you follow the advice being provided by Public Health England and the Versus Arthritis website, which are being reviewed and updated regularly. 

If you or anyone in your household has symptoms do not leave home – even to go to a GP surgery, pharmacy or hospital. If you have symptoms, please use NHS 111 online coronavirus service or call 111. 

You can find our Trust information relating to coronavirus here.

We appreciate this is very difficult time for all, and further government support can be found on their website.

What is the latest government advice about staying safe?

You can read the latest advice on staying alert and safe and information on staying safe outside your home. This is to reduce social interaction between people in order to reduce the transmission of coronavirus (COVID-19).

Some people are more vulnerable to COVID-19 infection than others. There is national guidance for people at higher risk.

Those who are considered to be in the moderate risk group (clinically vulnerable individuals) are advised to take additional precautions to minimise contact with people from outside the household. It is advised that such persons follow social distancing strictly. There is advice on social distancing here. The moderate risk group includes those who are over 70, women who are pregnant, those with BMI of 40 or above, and those with certain long term conditions, or if on certain medications that can affect immune system, such as low dose steroids or immunosuppressive medications.

Colchicine, Hydroxychloroquine and Sulfasalazine are NOT immunosuppressive medications, either alone or in combination. 

Please look at the Covid-19 risk stratification flowchart and refer to the purple box for a list of immunosuppressive medications used in rheumatology. Please note that steroids are also immunosuppressive, particularly at higher doses.

Who should follow the shielding advice?

Those who are considered to be in the high risk group (clinically extremely vulnerable individuals) are advised to shield. Shielding is a measure to protect people who are clinically extremely vulnerable by minimising all interaction between those who are extremely vulnerable and others.

Some of our patients in rheumatology will fall within this group and it is recommended that patients that fall under this group follow these measures to keep themselves safe. There is guidance from British Society for Rheumatology (BSR) and NHS England to aid in risk stratification.

Read the risk stratification chart to help identification of such clinically extremely vulnerable individuals based on the BSR guidance has been developed (adapted from Bradford rheumatology team). As guidance is updated, some people may fall in and out of the shielding group, so please review updated government advice and updated website advice.

We have now sent out letters to the clinically extremely vulnerable patients advising shielding as per national recommendation. This will enable such persons to register online for additional support.

Please note that such letters have also been sent out nationally and by GPs for some patients and there may be some discrepancy in the advice given by the different teams. If you have any queries regarding this, please inform us.

If you have not received the shielding advice letter but feel that you should have received it after looking through the AGH risk stratification chart (i.e. if you fall into any of the red boxes in the chart including if you have interstitial lung disease (pulmonary fibrosis) related to your rheumatological condition), please leave a message on the advice line, 01535 292084.

What is our advice about continuing on treatment?

Our general advice is to continue on your immunosuppressant medications because the health risk associated with a flare of your rheumatological disease is likely to be greater. This is because of;

(i) symptoms of your disease itself;

(ii) infection risk can be higher if your disease is not well controlled;

(iii) if you have a flare, the treatments needed to control the flare could be risky.

However, should you develop symptoms of infection, then we would recommend that your immunosuppressive treatment is paused for the duration of the infection but DO NOT stop steroids if you are on it (see below for advice). If you have concerns for infection, please seek medical attention and inform the rheumatology team.

There may be individual circumstances where your clinical teams may contact you to review your treatment, and this will be under ongoing review should any new evidence emerge about specific treatments.

Research is underway to explore the effectiveness of a number of drugs in treating this coronavirus infection, although information remains limited.

What about non-steroidal anti-inflammatory drugs/NSAIDs (eg. ibuprofen, naproxen)?

There have been reports in the media regarding anti-inflammatory drugs such as naproxen and ibuprofen.

There is currently no significant evidence that the use of ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs) increase the risk of developing Covid-19 infection or of developing a more severe Covid-19 disease.

It is advised that patients and/or carers can take paracetamol or ibuprofen when self-medicating for symptoms of suspected or confirmed Covid-19 infection as long as there is no medical reason for the person not to take it (e.g. NSAID use should ideally be avoided in people with significant heart disease, risk of internal bleeding such as heartburn or stomach ulcer, those with kidney impairment – not an exhaustive list). Every medication has its own benefits and risks, so please read the patient information leaflet before taking such medications. We advise that the anti-inflammatory medications are used at the lowest effective dose for the shortest possible period.

If you are already on NSAID medication for treatment of a long term condition such as arthritis, you can continue taking this medication even if you develop symptoms of suspected Covid-19 infection but you may wish to discuss about this with your doctor.

What do I do with my medications if I develop infective symptoms?

If you develop a viral infection, immunosuppressant medication (other than steroids) will need to be stopped temporarily, as with any infection, but this should be done in consultation with your clinical team. Please make sure you tell your treating doctors if you are taking steroids and/or other immunosuppressive medications.

What about steroid tablets (for example prednisolone) and adrenal insufficiency?

Steroids should NOT be stopped suddenly even if you develop infection symptoms. Please make sure you tell your treating doctors that you are taking steroids and/or immunosuppressive treatments. You can print out a ‘steroid alert card’ to keep with you. There is guidance on this during the pandemic from national endocrine and rheumatology societies.

Your body needs a small amount of steroids to function every day and this is made naturally in your adrenal glands. If you have a serious infection, your body needs extra steroids to function well during this time. Adrenal insufficiency occurs when your body cannot make this extra natural steroid. Some persons have a known diagnosis of primary adrenal insufficiency, but if you have been taking 5mg a day of prednisolone or more for 4 weeks or longer, this is likely to cause adrenal insufficiency. This can also occur once the dose of prednisolone has been reduced to below 5mg.

Patients with COVID-19 (coronavirus infection) may have high fever or other systemic symptoms for many hours of the day. In COVID-19 infection, therefore, the standard advice to double the usual prednisolone dose (when on doses of less than 15mg per day of prednisolone) in the event of significant intercurrent illness may not be sufficient. 

If you have coronavirus infection and are taking 5-19mg of prednisolone daily, you should take 10mg prednisolone every 12 hours while you are unwell. This will be an increase in your total prednisolone dose.

Patients taking 20mg prednisolone or more per day, should continue their usual dose but take it split into two equal doses of at least 10mg every 12 hours while you are unwell (for example, if on 30mg per day of prednisolone, take 15mg twice a day).

Should you develop coronavirus, you should drink plenty of fluids especially if there is possibility of you having adrenal insufficiency.

If you have any concerns about what to do with your medications, please contact the rheumatology advice line or your GP.

What about Vitamin D?

Our usual recommendation (even before the pandemic) has been that most people would benefit from regular vitamin D3 (Colecalciferol) supplements of 20 to 25 micrograms per day (which is the same as 800 to 1000 international units/units per day) during the winter months. However, Vitamin D needs to be avoided in a person with sarcoidosis unless specifically advised by your medical team, and there may be other instances when your doctor would have advised you not to take vitamin D (such as if you have raised calcium levels) and you should follow your doctor’s advice.

The supplements are available to buy in high street shops or online and are not usually prescribed.

The national recommendation during this current pandemic is that if you are not going outdoors often, you should consider taking a daily supplement with 10 micrograms (400 units) of vitamin D all the time.

If you are already taking daily supplements of 20 to 25 micrograms per day (800-1000 units per day) of Vitamin D3, we would advise that you continue taking this dose.

What about returning to work if I am at higher risk of Covid-19 infection due to rheumatological condition and treatment?

The current advice is:

  • Clinically extremely vulnerable individuals (high risk group discussed above; i.e. those who have received shielding letters) have been strongly advised not to work outside their homes. This shielding advice currently from the government is till the end of July 2020

  • Clinically vulnerable individuals (i.e. moderate risk group discussed above, who are at greater risk but not considered to be at as high a risk as those in the shielding group) have been asked to take extra care in observing social distancing and should consider discussion with their occupational health/ employee health team re possibility of remote working or whether they would need to go to work with appropriate measures as recommended by the government

  • We would advise you to contact your occupational health/employee health team

For more specific information about returning to work, read Working safely during coronavirus. This contains the most relevant information related to your line of work.

How is our service changing?

We have moved to telephone and video consultations for majority of consultations to reduce the need for patients to travel and attend hospital. We appreciate that this is a significant change in how the NHS has operated, but it is necessary to protect you and your family. Some services have been reduced (or temporarily cancelled) to help support essential hospital services during the pandemic. We are now in the process of reviewing our services to try and increase activity over the coming weeks to months as per national recommendation.

Please be wary of a large number of hoax emails, websites, tweets and text messages or advice online from seemingly legitimate ‘doctors’. Advice should be sought from the links provided in this document.

Local council advice/ support

Craven District Council 01609 780780

Bradford Council 01274 431000

Summary of links provided above

Versus arthritis https://www.versusarthritis.org/news/2020/march/coronavirus-covid-19-what-is-it-and-where-to-go-for-information/

 NHS advice on Coronavirus https://www.nhs.uk/conditions/coronavirus-covid-19/

NHS 111 online service https://111.nhs.uk/covid-19/

Government Coronavirus support https://www.gov.uk/find-coronavirus-support

NHS high risk patients https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk-from-coronavirus/whos-at-higher-risk-from-coronavirus/

Government Staying alert and Social distancing advice https://www.gov.uk/government/publications/staying-alert-and-safe-social-distancing/staying-alert-and-safe-social-distancing

Government advice staying safe outside your home https://www.gov.uk/government/publications/staying-safe-outside-your-home/staying-safe-outside-your-home

Government social distancing advice  https://www.nhs.uk/conditions/coronavirus-covid-19/staying-at-home-to-avoid-getting-coronavirus/staying-at-home-and-away-from-other-people/

Government advice on ‘Shielding’ and protecting the vulnerable https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

Working safely during coronavirus https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19

There is also support and information from:

Versus arthritis https://www.versusarthritis.org/news/2020/march/coronavirus-covid-19-what-is-it-and-where-to-go-for-information/

NRAS (National Rheumatoid Arthritis Society) https://www.nras.org.uk/news/coronavirus-what-we-know-so-far     

NASS (National Axial Spondyloarthritis Society) https://nass.co.uk/news/coronavirus-advice-for-people-on-biologic-therapy/

Vasculitis UK https://www.vasculitis.org.uk/news/coronavirus-covid-19 

ROS (Royal Osteoporosis Society) https://theros.org.uk/information-and-support/coronavirus-and-osteoporosis/


Covid19 Risk stratification flow chart AGH