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

 

This update has a section for clinicians and for patients.  Please follow this link if you are a patient seeking advice. 

 

7 June 2021

It is safe for uveitis patients to have a COVID-19 vaccination and they should be encouraged to do so.

A review of the literature on immunosuppression and risk of COVID-19 indicates there is no current evidence to support an increased risk of either hospitalisation or mortality from COVID-19 in patients on immunosuppressants including biologic therapies for chronic inflammatory disease.

Two international registries, for rheumatological diseases and inflammatory bowel disease, of several hundred patients, suggest that immunosuppressants and anti-TNF drugs are not associated with an increased risk of severe COVID-19.1,2  Two UK unpublished audits in uveitis patients (Leicester and Oxford) have found that there was no increase in COVID-19 infections in uveitis patients on immunosuppression, including steroids, compared to those on none 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 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, when previous novel coronavirus infections have been treated with corticosteroids, virus clearance is reduced.3,4  Conversely the steroid, dexamethasone is now routinely used to treat hospitalised COVID-19 patients on oxygen to mitigate the associated respiratory inflammatory syndrome.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 

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

Uveitis clinicians may advise risk reduction for patients on high dose steroids (more than 20mg prednisolone) or cyclophosphamide, particularly if there are co-morbidities.

Risk reduction includes following local restrictions on movement, avoiding unnecessary contacts, shopping online and where possible, working from home. These measures are all part of the current national strategy.

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

 

·        Encourage vaccination against COVID-19

·        Currently there is no evidence that immunosuppression including TNF inhibitors increases risk from COVID-19.

·        Promote the hands, face, space9 public health campaign

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

·        Uveitis patients do not need to stop treatment with prednisolone or immunosuppression

·        If prescribing a course of high dose steroids (>20mg/day), discuss reducing risk of exposure to COVID-19.

·        In the event of COVID-19 infection (or other intercurrent infections) patients on long-term steroids, should increase the dose according to Society of Endocrinology guidelines. Other immunosuppressants should be suspended until recovery, provided the risk of uveitis reactivation is low.

 

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-/