COVID-19 Updates

For the latest updates and advice on coronavirus (COVID-19), please visit the NHS website.

This page provides a summary of Formulary updates specific to the COVID-19 pandemic.

For Clinical Referral Guideline (CRG) updates specific to the COVID-19 pandemic, please click here. The NHS Devon CCG Medicines Optimisation Team have produced a COVID-19 Information and Guidance page, which features a frequently asked questions section, please click here.

Shared Care / SMS drug safety monitoring during the COVID-19 pandemic

In order to minimise the need for patients to attend NHS facilities for face-to-face contact, the frequency of drug safety monitoring has been temporarily extended in certain clinical circumstances. Thresholds for action remain unchanged.

The guidelines for each drug have been amended, showing clearly in a blue font in the monitoring section of each guideline the changes introduced to apply during the COVID-19 pandemic.

A very brief summary of changes can be found by clicking here. Prescribers should refer to the relevant individual guidelines for details, these can be found on the NHS Devon CCG website and via the relevant drug entries in the formulary.

Template letters are available to support practices in writing to their patients who are affected by these temporary changes to advise them of the revised monitoring arrangements and what this means for them. These can be found by clicking here.

Please note: These recommendations only apply to patients being treated in accordance with the Devon Specialised Medicines Service/ shared care guidelines; they do not apply to other clinical situations e.g. transplant patients or ad hoc individual arrangements between GPs and specialists – Prescribers should seek specialist advice for these patients.

***UPDATE 29/05/2020*** The incidence of patients in Devon infected with COVID-19 in the first surge has been much less than was initially feared. Given the current relatively low prevalence of COVID-19 in Devon and the uncertainty about how the situation will change over the next few months, practices may wish to consider conducting some of the deferred monitoring tests now. It is recognised that practices will have responded to the original guidance differently and that individual circumstances vary. Not all practices will be in a position to undertake additional monitoring at this time. Further information and a template patient letter can be found by clicking here.

***UPDATE 12/10/2020*** The relatively low prevalence of COVID-19 in Devon and established infection control measures in primary care have reduced the risk of exposure to infection for patients who need drug safety monitoring. A return to usual monitoring is therefore preferred, however it is acknowledged that the pandemic is resulting in ongoing capacity restraints in primary care. GPs should aim to undertake monitoring at the usual frequency wherever possible. GPs who are experiencing capacity challenges as a result of the pandemic may continue to institute the minimum monitoring requirements detailed in the individual guidelines if necessary. GPs are recommended to prioritise patients prescribed DMARDs, particularly the following groups, for usual monitoring:

  • Those aged 75 years and older
  • Those with cognitive impairment (where there may be concerns of a risk of taking an incorrect dose or non-compliance with the medication regimen)
  • Those with reduced renal function (GFR < 60mL/min/1.73m2)
  • Those with liver impairment e.g. chronic liver disease, impaired synthetic function such as cirrhosis
  • Those with a previous history of DMARD toxicity or history of bone marrow suppression with DMARDs
  • Those on combination therapy e.g. methotrexate and leflunomide (nb: no concern for combinations including sulfasalazine or hydroxychloroquine)

GPs should continue to seek specialist advice if they have any specific concerns about individual patients.

End of life symptom control for patients dying of COVID-19

National guidance: Guidance has been issued for end of life symptom control for when a patient is dying of infection with COVID-19, please see here.

Prescribing for end of life symptom control: Local prescribing guidance and a prescribing and medication administration records (PMAR) have been developed to support patients with COVID-19 infection who require end of life symptom control, please see here.

Prescribing information for symptom management via syringe driver: Local concise prescribing guidance has been produced to support practitioners in end of life care of patients in the community who require medicines for symptom management of COVID-19 via syringe drivers. Please see here.

End of Life Care Resource for GPs: A resource page for GPs providing guidance for end of life care of patients with COVID-19 is available here. The page includes symptom management and links to the formulary palliative care section 16.17 End of life symptom control for patients dying of COVID-19 where the national and local guidance shown above is also available. Other topics covered include: the conversation, treatment escalation plans/do not resuscitate orders, care at the time of death, bereavement advice and support, care for carers, and care for yourself.

Supply of medication for palliative care: please see here for a list of community pharmacies in Devon which maintain a minimum level of stock of more specialised medicines, including injectable medicines most likely to be used in the management of patients with COVID-19.

Managing pneumonia in the community during the COVID-19 pandemic

NICE has issued a COVID-19 rapid guideline (NG165): managing suspected or confirmed pneumonia in adults in the community (03 April 2020). The previous recommendations for severity assessment and management of community-acquired pneumonia have been revised for use during the COVID-19 pandemic. The antibiotics recommended in this guideline differ from the previous recommendations for treatment of community-acquired pneumonia. This decision was taken for clinical reasons and to support the supply chain. Points covered by the new guideline include:

  • Diagnosis and assessment
  • Differentiating viral COVID-19 pneumonia from bacterial pneumonia
  • Deciding about hospital admission
  • New antibiotic recommendations – doxycycline has become the first line agent (see full guideline for details)

NICE will review and update their guidance as knowledge and practice develops. Please remember to ensure you are using the current guidance.

Antibiotic treatment of pneumonia in adults in hospital during the COVID-19 pandemic

NICE has issued a COVID-19 rapid guideline (NG173): antibiotics for pneumonia for adults in hospital (01 May 2020). The guideline includes patients presenting to hospital with community-acquired pneumonia and patients who develop pneumonia in hospital. Please also refer to your local acute trust's antibiotic guidelines.

Treatment of patients requiring Vitamin B12 during the COVID-19 pandemic

The British Society of Haematology (BSH) has issued advice on the management of patients requiring vitamin B12 supplements during the COVID-19 pandemic. This guidance covers patients who receive vitamin B12 for diet-related conditions and for conditions which are not thought to be diet-related (e.g. pernicious anaemia, history of total/partial gastrectomy or achlorhydria, inflammatory bowel diseases).

In patients who have vitamin B12 deficiency which is not thought to be diet-related and who have received regular maintenance parenteral vitamin B12, liver stores of vitamin B12 will be adequate to allow for the omission of one or two three monthly injections to minimise the risk of transmission of COVID-19 from face to face interaction with a healthcare professional. See the guidance for advice for managing patients with symptoms in the weeks preceding the injection.

If a patient is intending to attend a healthcare facility for a vitamin B12 injection, they should be informed of the increase in risk of transmission of COVID-19.

Contraception guidance during the COVID-19 pandemic

Guidance has been issued from the Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists regarding contraception during the COVID-19 pandemic, please see here.

Rheumatological autoimmune, inflammatory and metabolic bone disorders during the COVID-19 pandemic

NICE has issued a COVID-19 rapid guideline (NG167): rheumatological autoimmune, inflammatory and metabolic bone disorders (03 April 2020). The following has been highlighted in the formulary to aid prescribers with patients having treatment with denosumab and zoledronic acid:

  • Do not postpone treatment with denosumab
  • Treatment with zoledronic acid can be postponed for up to 6 months

Advice for GPs regarding patients presenting in alcohol or opiate withdrawal to general practice during the COVID-19 pandemic

Issued by the Together Drugs and Alcohol Service: Exeter, East and Mid Devon, North Devon and South Devon ( not Torbay)

The Together Drugs and Alcohol Service has issued advice for GPs who may be contacted by patients presenting in opiate or alcohol withdrawal during the COVID-19 pandemic. This advice can be found here. The prescribers at Together are continuing to assess and start new patients onto opioid substitution therapy; referral is via phone, email or letter (see contact details). Guidance is provided on adjunctive treatment and symptomatic relief for patients withdrawing from opiates.

GPs should not initiate a medically assisted withdrawal from alcohol. Guidance is provided for GPs who are contacted by patients for advice regarding alcohol detoxification. For urgent medical advice, see contact details.

Valproate Pregnancy Prevention Programme: temporary advice for management during the COVID-19 pandemic

The MHRA has issued temporary guidance for specialists for initiation of valproate in female patients, and for annual review and pregnancy testing to support adherence to pregnancy prevention requirements during the pandemic. Annual reviews should not be delayed. Please see here

Routine immunisation programmes during the COVID-19 pandemic

Specific information regarding maintaining immunisation programmes (from NHS England (NHSE)) during the Coronavirus (COVID-19) pandemic can be found here.

Where possible, the routine immunisation programmes should be maintained and offered in a timely manner and non-scheduled vaccinations should still be given. Anyone with an appointment cancelled as part of COVID-19 response should be invited for vaccination as soon as possible.

Information contained in the document includes:

  • What personal protective equipment (PPE) should be worn when administering vaccines
  • Ordering vaccines during the COVID-19 pandemic
  • NHS Immunisations FAQs (for the public)

Routine access to remdesivir in the treatment of COVID-19

From 3 rd July 2020, an interim clinical commissioning policy has been put in place to define routine access to remdesivir in the treatment of COVID-19 across the UK.

Remdesivir is recommended to be available as a treatment option for patients hospitalised with COVID-19 (adults and children aged 12 years and older) in accordance with the criteria set out in the updated policy document (06 November 2020) (see interim clinical commissioning policy for more details). The commissioning policy has been updated to reflect the more positive position on remdesivir supply into the UK. The updated policy includes a clinical pathway and new criteria for initiation of treatment, risk assessment, reassessment and review. Co-administration of dexamethasone and hydrocortisone with remdesivir is included. The formulary entry for remdesivir can be found here.

Updated guidance for the management of musculoskeletal and rheumatic conditions with corticosteroids during the COVID-19 pandemic

For guidance which covers the management of patients with musculoskeletal and rheumatic conditions who are receiving corticosteroids, or require initiation of oral or IV corticosteroids, or require a corticosteroid injection during the pandemic, please click here.

The guidance is supported by the British Society of Rheumatology, the Royal College of General Practitioners and other professional bodies. It supersedes guidance issued by NHS England at an earlier stage in the pandemic. The guidance covers:

  • Maximum daily doses of prednisolone for a range of indications
  • Intramuscular injections, intra-articular injections for inflammation, and injections for musculoskeletal pain
  • Factors to consider in deciding whether to use an injectable corticosteroid during the pandemic

Corticosteroids in the treatment of COVID-19

Clinical guidance for dexamethasone and hydrocortisone in the treatment of patients with COVID-19 has been issued by the DHSC and NHSE. For more information, please see the CAS alert (issued 03 September 2020) which can also be found under the entries for dexamethasone and hydrocortisone in section 6.3.2. Glucocorticoid therapy

Management of anticoagulation during the COVID-19 pandemic

NHS England guidance on management of anticoagulant services during the Covid-19 pandemic. Please see here

NICE Covid-19 rapid guideline (NG186): reducing the risk of venous thromboembolism in over 16s with Covid-19. This guideline covers pharmacological venous thromboembolism prophylaxis for all patients being treated for COVID-19 pneumonia. It includes patients receiving treatment in hospital or in a community setting with input from hospital clinicians such as a 'hospital at home' service or COVID-19 'virtual ward'. Specific guidance is referenced for women who are pregnant or have given birth within the last 6 weeks. Please see here

MHRA advice (October 2020): Warfarin and other anticoagulants – monitoring of patients during the COVID-19 pandemic

There have been concerns over an apparent increase in the number of patients taking warfarin found to have elevated international normalised ratio (INR) values. Continued INR monitoring is important in patients taking warfarin or other vitamin K antagonists (VKA) if they have suspected or confirmed COVID-19 infection.

Some patients taking warfarin may have been switched to DOACs during the pandemic to avoid regular blood tests for INR monitoring.

Patients with COVID-19 may be treated with antibiotics in line with NICE guidance and may also be treated with antivirals.

Healthcare professionals are therefore reminded:

  • that acute illness may exaggerate the effect of warfarin tablets and necessitate a dose reduction
  • of the potential for drug-drug interactions between oral anticoagulants (i.e. VKA or DOACs) and certain antibiotics and antivirals and are advised to follow existing advice in product information
  • that warfarin treatment should be stopped before DOACs are started

Further information regarding the monitoring of patients taking warfarin and other anticoagulants (from the MHRA) during the Coronavirus (COVID-19) pandemic can be found here; including advice to give to patients.

Last updated: 24-11-2020

 

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