COVID- 19 and Immunosuppression Update for Clinicians and Patients

 

This update has a section for clinicians and for patients.

Please follow this link if you are a patient seeking advice. 

 

Uveitis National Clinical Study Group Immunosuppression and COVID-19 Update for Clinicians

6 November 2020

Uveitis National Clinical Study Group Immunosuppression and COVID-19 Update:

 

As we approach winter and face a second wave of coronavirus infections, we recognise that patients with ocular inflammatory disease and their doctors are seeking clarity about the risk of immunosuppression in COVID-19. This update contains a brief summary of the most up to date literature, a means to calculate risk in patients with COVID-19 and some principles for management. This guidance is intended to extend beyond the short-term ‘lockdown' restrictions until December 2nd .

 

The risk of poor outcomes from COVID19 in immunosuppressed patients can be separated into two categories: the risk of systemic corticosteroids and the risk from immunosuppression with immunosuppressants and biologic therapies.

 

There is no current evidence to support an increased risk of either hospitalisation or mortality from COVID-19 in patients on immunosuppressants and biologic therapies in chronic inflammatory disease populations.

 

Two international registries, one for rheumatological diseases and one for inflammatory bowel disease consisting of several hundred patients, suggest that neither immunosuppressants  nor anti-TNF drugs are associated with an increased risk of  severe COVID-19 disease.1,2  Two UK unpublished audits in uveitis patients (Leicester and Oxford) have also found that there was no increase in COVID-19 infections in uveitis patients on immunosuppression including steroids compared to those on no immunosuppressive treatment during the 1st wave of the pandemic. The data for children is similar to that for adults and a specific guidance for children on immunosuppression or with uveitis is found  here.

 

The relationship between corticosteroids and COVID-19 infection is more complex but it is possible that those on moderate or high dose prednisolone are at increased risk from COVID-19 infection.1  

 

Early COVID-19 is associated with a reduced immune response and historically, when other novel coronavirus infections have been treated with corticosteroids, virus clearance is reduced.3,4  

 

Conversely the respiratory inflammatory syndrome, which may occur as a result of coronavirus infection, is treated with the steroid, dexamethasone in hospitalised COVID-19 patients on oxygen.5 

 

Risk Assessment

 

Increasing comorbidities and age are associated with poor COVID-19 outcomes. The at-risk 6 groups are summarised on the NHS website, but have not taken into account emerging information about immunosuppressant medications.

 

The risk assessment for patients taking immunosuppression remains the responsibility of clinicians although risk prediction calculators, such as the  QCovid risk calculator, to aid clinical decision making are now available.7  The QCovid risk calculator predicts death and hospitalisation due to COVID 19 infection and broadly includes immunosuppressants and corticosteroids as variables. Its limitations are discussed in a BMJ editorial.8

 

We should be aware that some patients falling into clinically extremely vulnerable category as defined on government webpages are already being advised centrally

to shield via email and letter until December 2nd . Uveitis physicians do not need to participate in this process.

 

Risk mitigation during high dose steroid prescribing / for patients on cyclophosphamide within the last 6 months

 

  • If a patient is already shielding, and coping well, no further risk mitigation advice is required.

 

  • Uveitis clinicians may advise shielding on an individual basis for the duration of high dose steroids (more than 20mg prednisolone), particularly if there are co-morbidities, and if your patient is able from an emotional well-being perspective.

 

  • Following local restrictions on movement, avoiding unnecessary contacts and where possible, working from home are all part of the current national strategy for risk mitigation. Government guidance for all patients in the moderate risk group is suitable for those not shielding  and is summarised here.

 

Please access our  patient information section which  may be helpful to you. Additional guidance for clinicians can be found in previous COVID 19 pages of the Uveitis National Clinical Study Group.

 

Principles for management of uveitis patients

 

  • Currently there is no evidence that immunosuppression including TNFi to spare steroids are contraindicated in COVID 19 patients

 

  • Advise patients on immunosuppression or low dose steroids ( 10mg  or less) to follow guidance for those at ‘moderate risk'

 

 

  • Promote national and local restrictions for COVID19

 

  • Where possible, avoid sustained prescribing of >10mg/day prednisolone

 

  • We do not advise patients stop existing treatment with prednisolone or immunosuppression

 

  • If prescribing a course of high dose steroids, discuss shielding, taking into account mental health concerns and wellbeing

 

  • Offer remote consultations and virtual assessments where possible. A guide to follow up frequency and types of consultation is within the notes at the end of this document
  • In the event of systemic illness due to COVID 19 ( or other intercurrent infections) patients on long-term steroids, should increase the dose according to Society of Endocrinology guidelines

 

 

 

  1. Gianfrancesco M et al Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician reported registry. Ann Rheum Dis. 2020 Jul;79(7):859-866. DOI: 10.1136/annrheumdis-2020-217871
  2. Brenner EJ et al. Corticosteroids, But Not TNF Antagonists, Are Associated With Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases. Gastroenterology. 2020;159(2):481-491.e3. doi:10.1053/j.gastro.2020.05.032
  3. Arabi YM, Mandourah Y, Al-Hameed F, et al. Corticosteroid therapy for critically ill patients with Middle East respiratory syndrome. Am J Respir Crit Care Med. 2018;197(6):757-767. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29161116.
  4. Stockman LJ, Bellamy R, Garner P. SARS: systematic review of treatment effects. PLoS Med. 2006;3(9):e343. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16968120.
  5. RECOVERY Collaborative Group, Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with COVID-19—preliminary report. N Engl J Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32678530.
  6. Who is at higher risk from coronavirus? https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/
  7. Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: national derivation and validation cohort study BMJ October 2020;371:m3731 doi.org/10.1136/bmj.m3731
  8. Prediction models for covid-19 outcomes. Sperrin M, McMillan BMJ October 2020;371:m3777; doi.org/10.1136/bmj.m3777
  9. Hands, Face, Space. Public Health England . Coronavirus Resources. https://coronavirusresources.phe.gov.uk/Hands-Face-Space-/

 

 

 

Table 1  Guide to allocate appointment modality (Uveitis CSG Clinician Guidance June 2020)

 

Telephone/Video.

Could be done by an AHP/ shared care with an optometrist

F2F/Virtual alternating appointment*

F2F*

Adult anterior uveitis (normal IOP)

Inflammatory CNV

1st attendance

Scleritis follow up

Multifocal choroiditis / PIC

Endophthalmitis

Episcleritis

Peripheral vasculitis

Active panuveitis

Counselling/ discussion about IMT

Ocular cicatricial pemphigoid

Corneal inflammatory disease

 

Toxoplasmosis

Vasculitis at the posterior pole

 

Anterior/Intermediate Uveitis with cystoid macular oedema

Active uveitis  with secondary ocular hypertension/ glaucoma***

 

Post intravitreal implant***

Asymptomatic uveitis eg JIA+

 

Quiescent panuveitis, IU, posterior uveitis

Unexplained reduced vision/ high risk of visual loss in follow up

 

*This is a suggested guide, your case allocation may vary based on your clinical judgement 

**New patients could be  seen F2F but could be followed with alternate virtual/ F2F virtually or in some cases, just virtual follow up may be suitable according to your judgement. Suggested standard virtual clinic dataset: VA, IOP, Optos, CMO+ AF for choroidal disease

*** IOP may be measured in the community and data shared with your service to reduce frequency of hospital visits

+See USG guidance for management of ocular inflammatory disease patients during the COVID-19 pandemic for prioritisation of JIA face-to-face appointments.