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.

Latest news: we are introducing digital patient letters across our service. Read more here

COVID-19 advice for rheumatology patients

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 national guidance is periodically updated. 

https://www.nhs.uk/conditions/coronavirus-covid-19/

What is the advice for high risk patients, the CEV (Clinically extremely vulnerable) group?

Patients considered to be at high risk of Covid19 infection are included in the CEV group.

We have previously in 2020 identified patients (and updated the national database) who are likely to be in the CEV group via risk stratification based on the BSR (British society for Rheumatology) guidance.

The most recent government update as of 20 September 2021 is for CEV group of people to follow the same guidance as everyone else. The shielding programme has ended in England. However, there are still things you can do to keep yourself safe. Please click on the below links for updated national guidance.

https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/advice-for-people-at-high-risk/

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

What do you do if you have symptoms of coronavirus infection (Covid 19)/ When to self isolate

https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-and-treatment/when-to-self-isolate-and-what-to-do/

The following is the national advice.

Self-isolate straight away and get a PCR test (a test that is sent to the lab) on GOV.UK as soon as possible if you have any of these 3 symptoms of COVID-19, even if they are mild:

  • a high temperature
  • a new, continuous cough
  • a loss or change to your sense of smell or taste

You should also self-isolate straight away if:

Covid-19 vaccination

There is updated information about vaccination on the versus arthritis website

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

Which vaccines have been approved in the UK and who can have it?

Three vaccines are authorised by Medicines and Healthcare products Regulatory Agency (MHRA) for use in the UK: Pfizer/BioNTech, Oxford/AstraZeneca and Moderna. None of these vaccines are considered live and all are safe for use in immunosuppressed patients.

Immunosuppressed patients, as a result of medication or disease, are at high risk of severe illness from COVID-19. All patients should be encouraged to receive a COVID-19 vaccine, regardless of treatment regimen or underlying diagnosis. The benefits of the COVID-19 vaccination outweigh the risks and by having the vaccine, they reduce the risk of developing severe complications due to COVID-19.

How effective are the vaccines in immunosuppressed and immunocompromised patients?

Some patients on immunosuppression may not have mounted as good a response to the vaccine.

Initial data shows that a proportion of clinically at-risk patients with certain immunocompromised or immunosuppressed conditions mount a low or undetectable immune response after two doses of the same COVID-19 vaccine. The significance of these findings in terms of what they tell us about vaccine protection from exposure to COVID-19 is not currently known.

Am  I eligible for a 3rd ‘primary dose’ of the covid vaccine?

Based on new guidance published by the JCVI in September, a third vaccine dose close to their second COVID-19 vaccine dose, should be offered to those aged 12 years and over with immunosuppression. This is part of the primary vaccination schedule to enhance vaccine effectiveness. 

This is being advised as a precautionary measure to increase your immunity level and provide a better vaccine response, based on studies and experience with other vaccines. It is part of the primary course of vaccination and is separate to a booster vaccination (booster vaccination for people who received the 3rd primary dose will likely be in six months’ time, pending further advice).

Following JCVI advise, the BSR (British Society for Rheumatology) has advised a more practical approach to identifying such persons who would likely benefit from the 3rd primary dose. As per BSR advise, we recommend this 3rd primary dose for persons who were (have been) on immunosuppressive medications (such as Methotrexate, Azathioprine, Leflunomide, Ciclosporin, cyclophosphamide, Mycophenolate, Biologic medications such as anti TNF injections, JAK inhibitor therapies such as Baricitinib, Prednisolone at doses of more than 10mg per day) in the 3 months prior to either the 1st or 2nd dose of the covid vaccine;  and for Rituximab, if had the infusion in the 6 months prior to the 1st or 2nd dose of the covid vaccine. 

We are now sending out letters for patients who we feel are eligible for the 3rd primary dose inviting them to book in for the vaccine dose as soon as possible. Due to the number of potentially eligible patients, we are identifying patients using our electronic records but we are unable to review individual patient notes for this. It is possible therefore that individual circumstances may mean you are not be eligible for this (for example, if you started on immunosuppressive medication at least 4 weeks after you had the second dose of the Covid-19 vaccine).

If you have received letter to book in for the 3rd primary dose but feel that you are not eligible for this or if you are not keen on having this 3rd primary dose, or if you would like to discuss before you proceed, please contact advise line on 01535 292084.

This 3rd primary dose must be at least 8 weeks after your second dose of a Covid-19 vaccine. We are not allowed to vaccinate you any earlier than this. The advice is for most people to have the mRNA type of vaccine, of which Pfizer brand is used at Airedale hospital, even if you have had the Astra Zeneca vaccine previously. If you have concerns about getting the Pfizer vaccine, for eg, if you have severe allergies, please contact Airedale hospital Vaccination centre on 01535 294323 for advice.

You may have already received an invitation for the 3rd primary dose from your GP. If this is the case, please follow their instructions for receiving your third primary dose. The centres offering this vaccination for you are available overleaf.

Are there any specific recommendations based on the medication I am taking?

  • In those who have had rituximab infusions in the past 6 months, the antibody response to the vaccine is likely to be lower than expected. That means that the vaccine may not provide the same level of protection (compared with those who have not had rituximab). We still recommend that such persons should have the covid19 vaccination when available.
  • Other disease modifying medications/ immunosuppressive medications may potentially affect antibody response to the vaccination.
  • This includes oral prednisolone doses of 10mg per day or more for a month or more or higher doses for shorter duration.
  • It is important to note however that steroids (if you are on them) are often prescribed/ necessary to help control the inflammatory condition and we advise that you DO NOT alter the dose of steroids without advice from your clinical team first since doing so can have a detrimental effect on your health.
  • There is evidence for reduced antibody response to the flu vaccination (‘flu jab’) when a person is on Methotrexate; and that withholding Methotrexate for 2 weeks after the flu vaccine improves the antibody response. However there is a potential for flare of the underlying disease when methotrexate is withheld.

We do not know if this is the case for covid 19 vaccinations. Those patients who have an inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, spondyloarthritis) and have disease that has been well controlled for over 12 months, could consider not taking/ withholding methotrexate for 2 weeks after the dose of the covid 19 vaccine. However, there is a risk of flare of disease. Please contact us on the advice line if you have any queries or doubts regarding this.

For those on methotrexate for a different condition such as vasculitis, myositis, SLE/ lupus or related connective tissue disease, the risk of flare of disease can be significant if methotrexate is withheld and we would request such persons not to withhold methotrexate and to contact advice line to discuss with the clinical team.

  • We are advising that those on other DMARD/ biologic medications should continue taking these (unless there is another clinical reason to withhold this). If you have any queries regarding the above, please contact us on the advice line on 01535 292084

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

If you develop a significant infection including a significant viral infection (which can be due to coronavirus/ covid19) , immunosuppressant medication (other than steroids) will need to be stopped temporarily, 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. Please request for steroid alert card from, your local pharmacy.

There is guidance on steroids 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 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.

How is our service changing?

We continue to provide both remote (telephone and video) and face to face consultations. The rheumatology advice line service has been continuing throughout the pandemic. Some services may  need to be reduced (or temporarily cancelled) to help support essential hospital services depending on the situation with the pandemic.

Local council advice/ support

Useful links

 Versus arthritis

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

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

NASS (National Axial Spondyloarthritis Society)

https://nass.co.uk/news/covid19-coronavirus/

Vasculitis UK

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

 NHS advice on Coronavirus

https://www.nhs.uk/conditions/coronavirus-covid-19/

Link to How to look after yourself at home if you have covid 19

https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-and-treatment/what-to-do-if-symptoms-get-worse/

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/

Working safely during coronavirus

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