COVID-19

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Clinical specialisms have been asked to provide information on medicines in relation to COVID-19; this will be added as it is produced.

NHS Inform for patient information   

NHS Highland IntranetIntranet for Health Board and Government advice (NHS Highland intranet access required)

for rapid guidelines and evidence reviews

ACE inhibitors and Heart failure

The Council on Hypertension of the European Society of Cardiology wish to highlight the lack of any evidence supporting harmful effect of ACE inhibitors and Angiotensin II Receptor Blockers (ARB) in the context of the pandemic COVID-19 outbreak.

It strongly recommends that physicians and patients should continue treatment with their usual anti-hypertensive therapy because there is NO clinical or scientific evidence to suggest that treatment with ACE inhibitors or ARBs should be discontinued because of the COVID-19 infection.

NHS Highland recommends to also follow this guidance for patients with heart failure.

Antibiotic Management during COVID-19

Interim advice to clinical staff on antibiotic management/antimicrobial stewardship in the context of the COVID-19 pandemic can be found here.

Clozapine treatment during COVID-19

There are over 3500 patients in Scotland prescribed the second generation antipsychotic, clozapine. Continuing an unbroken supply of clozapine is essential to maintaining their mental health and well being and preventing relapse.  Clozapine supplies are linked to mandatory full blood count monitoring at weekly, fortnightly or 4 weekly intervals. The COVID-19 outbreak presents a unique challenge to the continuous and safe maintenance of clozapine treatment. This document provides a potential approach to the management of clozapine patients during this national emergency.

There are three main issues to consider

  1. Maintaining routine full blood counts
  2. Maintaining prescription supplies
  3. Providing appropriate patient advice
1. Maintaining routine full blood counts

COVID-19 may result in patients self-isolating and being unable to attend for their full blood counts or being reluctant to travel to clinics for sampling. Similarly there may be staffing issues that mean it becomes very difficult to maintain normal clinic approaches. In both instances a pragmatic approach is required that supports patient safety with regards to clozapine monitoring but also reflects the realities of the COVID -19 outbreak.

  • For patients self-isolating: use the maximum validity possible between blood samples i.e.
    • Weekly patients 14 days. Mylan apply a 10 day validity to samples but we have 10 years experience of applying 14 days so the increased risk is acceptable. Note treatment from day 10 – 14 with Clozaril would be unlicensed
    • Fortnightly patients 21 days
    • 4 weekly patients 42 days

Given the current isolation advice this should support on-going dispensing in most instances.

Note: flu-like symptoms and a high temperature may suggest neutropenia so it is important to undertake a full blood count as soon as possible.

  • For patients who can’t or won’t travel to their usual blood sampling location:
    • Strongly urge patients to attend as normal
    • Use the maximum validity possible between blood samples
    • Consider undertaking blood sampling in patients’ homes
  • Services unable to undertake normal blood sampling processes:
    • If it proves impossible for services to undertake normal blood sampling processes consider dispensing off license without blood testing. This will require approval from a consultant psychiatrist on a case by case basis
2. Maintaining clozapine supplies

Clozapine supplies to patients must be maintained to prevent unnecessary treatment breaks and potential relapse. The following actions are recommended

  • Dispense to the maximum blood validity where necessary: most patients should continue to receive their normal supplies however it may be necessary and appropriate to dispense to the full blood count validity to support self-isolation or blood sampling difficulties
    • Continue to dispense without a valid blood: depending on individual circumstances or service issues it may be necessary to dispense prescriptions without any valid bloods being available. This should be a last resort and would be unlicensed. This will require approval from a consultant psychiatrist on a case by case basis
  • Prescription collection: normal prescription collection or delivery processes may be disrupted. Patients should be advised to contact their local Community Mental Health Team or New Craigs pharmacy for advice if they are unable to collect their medicines themselves.
3. Providing appropriate patient advice

Patients will be understandably anxious at this time providing appropriate reassurance may be necessary. Patients should be advised to follow national guidance about self-isolation and other measures but also to contact New Craigs pharmacy for advice about blood testing.

4. Dose management

There is no clear evidence regarding the impact of COVID-19 on clozapine plasma levels. A pragmatic approach is advised.

  • For patients with mild respiratory symptoms maintain the current dose and consider taking a trough clozapine plasma level (10-14 hours post dose)
  • For patients with severe respiratory symptoms suspend clozapine treatment until the symptoms resolve
  • For smokers who are unable to continue smoking due to illness consider a dose reduction
Other issues to consider

Amber & red alert protocols
Twice weekly blood tests for amber results should be attempted but may be impractical and therefore consideration should be given to maintaining standard routine blood tests for amber results. Consideration of individual patient circumstances i.e. previous blood results history will be necessary.

Daily blood tests following a red result may also be impractical for community based patients. Consideration should be given to admitting all red alert patients to hospital to support the necessary blood testing.

Clozapine new starts and red re-challenges
Consideration should be given on a case by case basis to the benefits and risks of new starts and especially red re-challenges. Given the uncertain effects of COVID-19 on white blood cells it may be prudent to avoid exposing previously neutropenic patients to clozapine at this time.

Cystic fibrosis (Cf)

All patients with cystic fibrosis will have a Cf care plan on sci store detailing their action plan, including admission to hospital.

All patients with cystic fibrosis should have reserve oral medication at home.

For patients on CFTR modulators - Orkambi, Symkevi and now tezacaftor - their GPs have been sent letters about the drug to drug interactions.

In the interim, and while service allows, the Cf Clinical Nurse Specialist will continue to carry out therapeutic drug monitoring for those those who have just started on treatment or who already have abnormal LFT's.

Ibuprofen, NSAIDS and COVID-19

Alert Reference: CEM/CMO/2020/010: Novel coronavirus: Anti-inflammatory medications (ibuprofen) 
Date of issue: 17 March 2020

Renal

Letters have been sent to renal patients on immunosuppression advising them of general information regarding COVID-19.
Useful advice for patients can be accessed at https://www.kidneycareuk.org
Transplant patients and patients on immunosuppression have now been advised to self-isolate for twelve weeks.

Patient with symptoms of COVID-19

Patients have been advised NOT to come to the renal unit if they have symptoms of COVID-19. They should ring 111.
Transplant patients and patients on immunosuppression with symptoms should also phone the renal unit on 01463 705623, 704383 or 705861.
The renal team will alert a Consultant that the patient is phoning 111. This will allow them to make any plans that may be needed.

Appointments

Patients have been asked to be flexible about clinic appointments. Most will be undertaken by phone and, where possible, many will be deferred.

Medication

Transplant patients:

The large majority of people on anti-rejection medicine who get flu recover. At present we do not know if the anti-rejection medicine puts you at more risk of complications from COVID infection, but –
**It is very important that you continue to take your anti-rejection medication**

Patients on immunosuppression:

The large majority of people on immunosuppressive medicine who get flu recover. At present we do not know if the immunosuppressive medicine puts you at more risk of complications from COVID infection, but –
**It is very important that you continue to take immunosuppressive medication unless advised otherwise by your kidney doctor**

Medication supply:

We ask that patients ensure they always have at least one month supply of their immunosuppressive/anti-rejection medication. Community pharmacy delivery services should be utilised to ensure that patients self- isolating are able to receive essential medication supplies. Please contact the renal team if it is not going to be possible for you to supply a patient’s medication before they run out.

 

Rheumatology

The guidance the NHS Highland Rheumatology Department is following is listed on the British Society of Rheumatology Website and is subject to frequent updates. Patients are advised to check this as we will continue to follow any changes in advice that are issued at a national level.

In summary (as of 19/3/20)
Patients who are established on biologic therapy or disease modifying therapy should continue treatment in order to keep their disease under control. It is not felt that stopping treatment is in a patient's best interest and is unlikely to reduce chances of catching COVID-19 or reduce the effects of it if they do catch it.
Having to come to hospital with a flare of disease as a consequence of withholding treatment would be counter-productive.

We will be cautious starting new treatment at present and will discuss the individual patient's pros and cons of doing so at the time of clinic appointment.

If a rheumatology patient should catch a significant infection, COVID-19 or otherwise then, in keeping with current advice, both disease modifying therapy and biologic therapy should be withheld for the duration of the illness. In addition we would not recommend the use of NSAIDs (eg ibuprofen, naproxen, celecoxib) during the illness.

Information for patients

All patients on immunomodulating drugs and those with inflammatory joint disease are advised to follow the guidance on social distancing as advertised nationally and in the British Society of Rheumatology Website.
We cannot give individual advice on suitability for continuing in the workplace. This needs to be discussed with your own line manager and occupational health department. National guidance will be advertised in the press and we advise all line managers to follow this advice when it is available.

Elderly patients, patients with heart disease and other chronic conditions, including those on immunosuppressive therapy are considered high risk - please see Public Health England guidance on social distancing.

Patients may decide that they do not need to follow this advice and would not need to inform us if they decide to stop treatment.

Editorial Information

Last reviewed: 18 March 2020

Next review: 23 April 2020

Author(s): Lead Clinician and Pharmacist for each specialism

Version: 1

Approved By: Awaiting approval from TAM subgroup