National Institute for Health and Clinical Excellence (NICE)
NICE publishes new COVID-19 guidelines on cystic fibrosis, chronic obstructive pulmonary disease (COPD) and dermatological conditions treated with drugs affecting the immune response
NICE recently (9 April 2020) published 3 new rapid guidelines on the care of patients with suspected and confirmed COVID-19, and in patients without COVID-19. The guidelines have been designed to maximise the safety of patients whilst enabling services to make the best use of NHS resources.
They cover the care of patients with cystic fibrosis, COPD and dermatological conditions treated with drugs affecting the immune response.
The guideline on cystic fibrosis makes clear that patients should be supported to continue with all their usual self-care arrangements. It also explains that patients can still access cystic fibrosis transmembrane conductance regulator (CFTR) therapies under the NHS England policy statement for these drugs.
The guideline highlights government guidance on shielding and protecting patients with cystic fibrosis, who are extremely vulnerable from COVID-19, and recommends several ways in which care can be provided to minimise face-to-face contact and visits to hospital. It gives recommendations for patients with possible COVID-19 and says that members of the cystic fibrosis team should be involved in decisions about their care, including escalation of treatment.
So that patients have the support they need, and their care can be safely managed out of hospital as much as possible, the guideline says that sufficient clinical expertise and capacity should be maintained within the cystic fibrosis team. It also highlights that some patients, families or carers may need specialist psychological or social work support in the context of COVID-19.
Given the severe capacity constraints because of managing the Covid-19 pandemic, the guideline recommends that the transition of young people to adult services should be deferred until the pressures associated with the COVID-19 pandemic have passed.
The guideline on COPD recommends that patients should continue taking their regular inhaled and oral medicines, including corticosteroids, in line with their individualised self-management plan to ensure their COPD is as stable as possible. This includes those with COVID-19, or suspected of having it. It also recommends that patients with COPD who are still smoking should be strongly encouraged to stop smoking in order to reduce the risk of poor outcomes from COVID-19 and their risk of acute exacerbations.
If they develop symptoms of COVID-19, the guidance advises that patients should not start a short course of oral corticosteroids and/or antibiotics. It also says they should not routinely start prophylactic antibiotics to reduce their risk from COVID-19.
Patients using non-invasive ventilation at home should be advised that, because these are potentially infectious aerosol-generating procedures, they should take appropriate precautions such as using equipment in a well-ventilated room and using it away from other family members if possible.
The guideline on dermatological conditions treated with drugs affecting the immune response says that, for patients known or suspected to have COVID-19, they should continue topical treatments (ones that are applied to the skin), and that the use of topical treatments rather than systemic treatments that affect the immune system should be considered for any new skin conditions .
When deciding to start or continue treatment with a drug that affects the immune system, the guideline recommends that factors like whether it is essential to start with the drug immediately, or continue with the drug, or whether any changes can be made to the dose or how it is given that could make hospital attendance or admission less likely, could be considered.
The guideline also advises that these patients should not suddenly stop taking oral corticosteroids. They can also continue to take hydroxychloroquine, chloroquine, mepacrine, dapsone and sulfasalazine, but consider temporarily stopping all other oral immunosuppressive therapies, novel small-molecule immunosuppressants, biological therapies and monoclonal antibodies.
Further guidelines will be announced in due course and will include acute cardiac injury and immunosuppressant medicines for gastrointestinal conditions. NICE will publish new guidelines, each based on the priorities for patients and the NHS.
NICE will also make the guidelines internationally available so that health systems around the world can see the approach the UK is taking.
The guidelines are being produced in collaboration with NHS England/Improvement and a cross-specialty clinical group, supported by the specialist societies and Royal Colleges.
- NICE has identified its appraisal of Elexacaftor, tezacaftor and ivacaftor fixed dose combination therapy for treating cystic fibrosis with the F508del mutation as being a therapeutically critical topic within the context of COVID-19. Therefore it has been categorised as a priority topic in the work programme.
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