Last reviewed: July 2020
Last updated: August  2020
05 Aug 2020

Guidelines recommend measures to manage acute and chronic conditions during the COVID-19 pandemic: updated

Further guidelines have been published to inform the management of patients with coexisting conditions during the COVID-19 pandemic.

New this update:

  • Abnormal uterine bleeding

  • Chronic pain

  • Considerations for gastrointestinal motility tests

  • Obesity in adults

  • Strongyloides infection

  • Systemic lupus erythematosus

  • Acute kidney injury (updated)

  • Haematopoietic stem cell transplantation (updated)

  • Considerations for patients receiving radiotherapy (updated)

  • Osteoporosis (updated)

  • Rheumatoid arthritis (updated)

Original source of updateexternal link opens in a new window

Introduction

Considerations for perinatal care

Considerations for newborn care

Considerations for patients with dermatological conditions receiving drugs that affect the immune response

Considerations for patients with gastrointestinal or liver conditions treated with drugs that affect the immune response

Considerations for patients with lower gastrointestinal symptoms

Considerations for endoscopy

Considerations for patients receiving systemic anti-cancer therapy

Considerations for patients receiving radiotherapy

Considerations for patients with head and neck cancer

Considerations for patients with neuromuscular diseases

Use of ACE inhibitors and angiotensin-II receptor antagonists

Routine immunisation

Considerations for patients who require anticoagulation

Considerations for management of patients in community psychiatry services

Mental health of children and adolescents

Considerations for the mental health of healthcare workers

Considerations for immunocompromised children and young people

Safeguarding children and young people

Use of valproate

Considerations for cardiac investigations

Considerations for patients with cardiac implantable electronic devices (CIEDs)

Considerations for laparoscopy

Considerations for gastrointestinal motility tests

Considerations for elective surgery

Potential impact of COVID-19 pandemic on diagnosis of other conditions

Resources

Condition
Description

Our full topic on Coronavirus disease 2019 (COVID-19) includes information on diagnosis and management, as well as prevention, differential diagnosis, epidemiology, aetiology, prognosis, and complications.

A Cochrane review has evaluated the effectiveness and safety of treatments for heavy menstrual bleeding that are commonly available during pandemics.[99] Treatments evaluated included non-steroidal anti-inflammatory drugs (NSAIDs), antifibrinolytics, combined hormonal contraceptives, and progestogens. The review found that there is moderate-certainty evidence that antifibrinolytics and combined hormonal contraceptives reduce heavy menstrual bleeding compared with placebo; there is low‐certainty evidence that NSAIDs reduce heavy menstrual bleeding compared with placebo; and there is low‐certainty evidence that antifibrinolytics are more effective in reducing heavy menstrual bleeding when compared with NSAIDs and short‐cycle progestogens. The authors were unable to draw conclusions about the effects of antifibrinolytics compared with long‐cycle progestogens and no conclusions could be made about quality of life, patient satisfaction with treatment, or serious adverse events. The review’s authors suggest that within the context of a pandemic when treatment is selected remotely, antifibrinolytics (e.g., tranexamic acid), NSAIDs, and combined hormonal contraceptives can be offered. They also emphasise the importance of providing a complete face-to-face assessment (physical examination, blood tests, ultrasound) when services are available.

Patients with COVID-19 may develop acute kidney injury (AKI), proteinuria, or haematuria. AKI is a risk factor for in-hospital mortality.[100] Hospitalised adults with COVID-19 may have a higher incidence of AKI and may be more likely to require renal replacement therapy compared with those without COVID-19.[101] The aetiology of AKI in COVID-19 is probably multifactorial and is incompletely understood. Patients with elevated body temperature and increased respiratory rate will have greater insensible fluid losses.[102] The treatment of AKI in patients with COVID-19 appears to be the same as in other populations, including continuous renal replacement therapy if necessary.[103] UK guidelines recommend checking fluid status and biochemistry for all patients admitted to hospital with suspected or confirmed COVID-19.[104] Intravenous fluids are required in many cases, and choice should be guided by biochemistry. The goal is to maintain a euvolaemic state. Hypernatraemia is common at presentation and can also develop later.[102] Medications that can cause or worsen AKI should be stopped unless essential. Potassium binders can be used as part of the emergency management of life-threatening hyperkalaemia, alongside standard care. These agents may have a role in preventing or delaying the need for renal replacement therapy if resources are limited.[102][105]

An international expert panel and the American Society of Hematology have made recommendations for the treatment of adult acute lymphocytic leukaemia. Clinicians should consider minimising corticosteroid exposure and reducing doses of daunorubicin and pegaspargase (pegylated asparaginase) during treatment induction in older people. Anti-CD20 monoclonal antibodies reduce immunoglobulin levels; treatment with these agents should be deferred if possible. Second-generation tyrosine kinase inhibitors with reduced dose corticosteroids should be considered in Philadelphia chromosome-positive disease.[106][107]

Clinicians should consider blinatumomab if patients are positive for minimal residual disease after two cycles of chemotherapy. If patients are negative for minimal residual disease and have received most of their chemotherapy, they may be advanced to maintenance. During maintenance, clinicians should consider reducing corticosteroids and avoiding vincristine in patients >65 years. Recommendations are given for relapsed or refractory disease and transplantation. Growth factor support should be considered in patients without COVID-19 to facilitate neutrophil count recovery and maintain absolute neutrophil count above 1000 cells per microlitre during all phases of treatment. Growth factors should probably be avoided in patients with moderate-to-severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection because there is a potential risk of exacerbating inflammatory pulmonary injury.[106][107]

Patients with acute myelogenous leukaemia (AML) should be screened for COVID-19 before starting induction or consolidation chemotherapy.[107][108] Patients receiving intensive therapy should, ideally, be barrier nursed in a COVID-19-negative ward with enhanced screening and protection measures. Chemotherapy should be delayed until the resolution of symptoms and the patient has a negative polymerase chain reaction test. Cytogenetics and nucleophosmin-1 (NPM1) and fsm-related tyrosine kinase-3 (FLT3) status will guide choice of chemotherapy. Venetoclax and gilteritinib have been granted emergency approval from NHS England for use in selected patient groups.[109]

Growth factors should probably be avoided in patients with moderate-to-severe COVID-19 because there is a potential risk of exacerbating inflammatory pulmonary injury.[106]

Patients with adrenal insufficiency are at an increased risk of infection, which may be complicated by developing an adrenal crisis. Guidance on prevention of adrenal crisis in patients with confirmed or suspected COVID-19 is available.[110] Patients should be given support to help them self-manage their condition safely and should be educated in the use of sick day rules. The guidelines recommend that patients with symptoms of COVID-19 should seek medical advice, and should take oral hydrocortisone or prednisolone as directed. Patients are also advised to take paracetamol for fever, and to drink regularly, monitoring how concentrated their urine appears. If there are signs of clinical deterioration (such as dizziness, intense thirst, shaking uncontrollably, drowsiness, confusion, lethargy, vomiting, severe diarrhoea, increasing shortness of breath, respiratory rate >24/min, difficulty speaking) the patient or carer should inject hydrocortisone intramuscularly and call for emergency medical assistance.[110] Hospitalised patients should receive intravenous hydrocortisone and continuous intravenous fluid resuscitation with isotonic saline; fludrocortisone should be temporarily stopped.

Statements from the British Society for Allergy and Clinical Immunology and the Italian Society of Pediatric Allergy and Immunology advise that patients with allergic rhinitis should continue usual treatment, including topical intranasal corticosteroids and antihistamines. Uncontrolled allergic rhinitis may lead to sneezing and increased hand-eye and hand-nose contact, facilitating severe acute respiratory syndrome coronavirus-2 transmission.[111][112] Skin testing for aeroallergens, sublingual immunotherapy, and subcutaneous immunotherapy should be deferred. Post-dose observation may be decreased and intervals between doses may be increased for patients already taking subcutaneous immunotherapy.[111]

The definitive treatment options for severe aplastic anaemia (AA) are stem cell transplant or immunosuppressive therapy and while there is currently little evidence about the course of COVID-19 in people with AA, they may be at higher risk of infection and complications. The American Society of Hematology advise that for patients with absolute neutrophil count (ANC) <200/microlitre (very severe AA) the risk of delaying transplant or immunosuppressive therapy outweighs the risks of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during hospitalisation or the impact of immunosuppression on the course of infection, but that optimal management may not currently be practical.[113]

Immunosuppressive treatment options are antithymocyte globulin (ATG), ciclosporin, and eltrombopag; administration of ATG requires hospitalisation. The American Society of Hematology, the European Society for Blood and Marrow Transplantation, and NHS England have released statements recommending the use of eltrombopag, with or without ciclosporin, as bridging treatment to stem cell transplant or immunosuppressive therapy with ATG for patients with severe or very severe AA during the COVID-19 pandemic.[113][114][115]

Patients should continue taking their prescribed asthma medication as usual, including inhaled and oral corticosteroids and biological therapy.[116][117][118][112][119][120] The Global Initiative for Asthma (GINA) advises that all patients should have a written action plan so they know how to recognise worsening asthma, how to increase reliever and controller medications, and when to seek medical help. GINA advises that nebulisers should be avoided for acute attacks due to the risk of transmitting respiratory viral particles, and that a pressurised metered-dose inhaler and spacer with mouthpiece or tightly fitting face mask can be used to deliver a short-acting beta-2 agonist instead.[116] The US Centers for Disease Control and Prevention advises that nebuliser administration may generate infectious aerosols; however, it is unclear whether association between nebuliser administration and infection is due to the generation of infectious particles or the close contact between the patient and healthcare professional administering the nebuliser.[121] However, UK guidelines advise that nebulisers may continue to be used, as the aerosol comes from the fluid in the nebuliser chamber and will not carry virus particles from the patient.[117] Bronchoscopy and most pulmonary function tests such as spirometry should only be done for urgent cases and if the results will have a direct impact on patient care.[116][117]

Patients should ensure they have a sufficient supply of medication at home, but should not stockpile. Patients may be reminded that they should not share inhalers or spacers with others. Clinicians should encourage smoking cessation.[112]

Advise patients that COVID-19 may present with symptoms similar to an asthma attack (e.g., cough, shortness of breath); however, additional symptoms such as fever, fatigue, and change in taste or smell are more likely to suggest COVID-19 infection.[122]

The European ADHD guidelines group have published guidance for management of patients with ADHD during the COVID-19 pandemic. Service provision should continue using telehealth where possible. Parents or carers are encouraged to use behavioural parenting strategies and schools are advised to prioritise monitoring of students with ADHD. Patients should be offered the opportunity to start on medication, if indicated, following an initial assessment. Patients who are already established on medication should continue taking it as prescribed. Parents and patients should not increase medication doses above the dose prescribed to manage the stress of confinement. Routine cardiovascular examination and face-to-face monitoring can be deferred for individuals without any cardiovascular risk factors. Home blood pressure and heart rate monitoring is recommended.[123]

The American Society of Breast Surgeons has released recommendations for the prioritisation, treatment, and triage of patients with breast cancer during the COVID-19 pandemic.[124] The highest-priority conditions for treatment during the pandemic are:

  • Potentially unstable breast disease (e.g., haematoma, infection): assessment and surgery

  • New diagnosis of invasive breast cancer (may be suitable for telemedicine)

  • Surgery: revision of ischaemic mastectomy flap; revascularisation/revision of autologous tissue flap

  • Chemotherapy: neoadjuvant/adjuvant chemotherapy for triple-negative and HER2-positive breast cancer; early chemotherapy likely to improve outcomes in metastatic disease; completion of adjuvant/neoadjuvant chemotherapy that has already started; adjuvant or metastatic endocrine therapy

  • Radiotherapy for painful, inoperable breast masses; continuation of radiotherapy that has started; treatment for critical metastatic lesions (e.g., brain metastasis, spinal cord compression).

UK guidelines recommend giving highest priority to patients receiving:[32]

  • Curative systemic anti-cancer treatment with a high (more than 50%) chance of success

  • Adjuvant or neoadjuvant systemic anti-cancer treatment that adds at least 50% chance of cure to surgery or radiotherapy alone or treatment given at relapse.

The UK Association of Breast Surgery has published recommendations for delivering breast services during the pandemic. New referrals should be triaged and patients should be contacted before clinic attendance. Patients with COVID-19 symptoms should self isolate for 7 days and their appointment deferred until after self isolation. Patients should be seen in person where there is a strong suspicion of cancer; patients with low suspicion of cancer (e.g., breast pain, or bilateral nipple discharge in a woman <30 years) may be contacted by telephone and considered for deferred imaging. Frail, older patients with comorbidities or who require residential care are at highest risk from COVID-19. Therefore, these patients should not be seen in person. Empiric letrozole treatment may be considered. Follow-up for existing patients should be performed by telephone where possible.[125]

Capacity for surgery is limited in many hospitals. The Association of Breast Surgery suggests prioritising patients in the following order:[125]

  • Oestrogen receptor (ER) negative

  • Human epidermal growth factor receptor 2 (HER2) positive

  • Pre-menopausal patients

  • Post-menopausal, ER positive patients with high risk disease (grade 3 or node positive)

  • Large areas of high grade ductal carcinoma in situ (DCIS)

  • Post-menopausal, ER positive patients with lower risk disease

  • Remaining patients with DCIS 

Neoadjuvant chemotherapy should only be given where it is clear that chemotherapy is indicated, and would be given in the adjuvant setting. Neoadjuvant chemotherapy should be routinely supported with granulocyte-colony stimulating factor during the pandemic. Multidisciplinary team discussion is recommended for all cases.[126]

Further oncology resources are available at:

Giving CPR poses a high risk to healthcare workers in the context of COVID-19 due to the aerosol-generating procedures, close proximity of multiple healthcare workers and the patient, and the need to work quickly.

If cardiac arrest is recognised (patient is unresponsive and breathing abnormally) look for breathing, but do not open the airway or listen/feel for breathing by placing the face close to the patient's mouth.[127][128][129]

In acute hospital settings, full Aerosol Generating Procedure (AGP) Personal Protective Equipment (PPE) must be worn by all members of the resuscitation team before entering the room; no chest compressions or airway procedures should be started without full AGP PPE. The number of staff in the room should be restricted, and airway interventions should be done by experienced staff, minimising aerosolisation risk.[127][128][129][130]

In first aid and community settings, lay-rescuers should perform compression-only resuscitation and defibrillation (where there is access); a cloth may be placed over the patient's mouth and nose if there is a perceived risk of infection. Paediatric cardiac arrest is more likely to be caused by a respiratory problem, and ventilation is vital; lay-rescuers may consider that the risk of not giving rescue breaths could be greater than the risk of transmission of COVID-19.[127][128][129][130]

Brazilian guidelines recommend beginning continuous chest compressions to deliver CPR to adults. The patient’s oral cavity should be sealed with a cloth or a mask providing low flow (6-10 litres/minute) oxygen before starting chest compressions; the seal should be kept in place until an invasive airway is secured. Bag-valve-mask or bag-valve tube ventilation should be avoided if possible; if it is needed, two rescuers should provide ventilation (to allow a two-handed seal around the mask) and an oropharyngeal airway should be used. A high-efficiency particulate arrestance (HEPA) filter should be placed between the mask and bag. If the patient is prone at the time of cardiac arrest and does not have an invasive airway, they should be repositioned supine. If the patient is intubated, chest compressions should be delivered while prone. Resuscitation of children should ideally be with chest compressions and use of a bag-valve-mask apparatus with a HEPA filter until a definitive airway is established.[131]

People of any age with chronic kidney disease (CKD) are at increased risk of severe illness from COVID-19.[132] The UK National Institute for Health and Care Excellence has published guidelines for managing patients with CKD during the COVID-19 pandemic. Patients should be advised to continue taking their usual medications, even if they have symptoms of COVID-19, unless directed otherwise by a healthcare professional. This includes ACE inhibitors, angiotensin-II receptor antagonists, immunosuppressants, and diuretics. Patients should be advised to keep a list of their medications, other medical conditions, and allergies and a copy of a recent clinic letter to give to healthcare staff if they need treatment for COVID-19. Clinicians should review the medication of any patients diagnosed with COVID-19, taking into account whether any have the potential to adversely affect renal function. When deciding whether to admit a patient who has CKD and COVID-19 to hospital, clinicians should consider the patient's wishes, the severity of CKD, any comorbidities, whether the patient is taking any immunosuppression, the risks and benefits of admission, and how the care that can be offered in hospital compares with care that can be offered at home. All patients with advanced CKD should have the opportunity to participate in advance care planning.[133]

After recovery from COVID-19, renal function should be reassessed. The urgency of assessment should be based on the patient's glomerular filtration rate (eGFR) category, comorbidities, and clinical circumstances.[133]

Urgent outpatient appointments are needed for: patients with accelerated progression of CKD (a sustained decrease in GFR of 25% or more and a change in GFR category in the preceding 12 months, or a sustained decrease in GFR of 15 mL/min/1.73 m² per year); nephrotic syndrome or very severe proteinuria (urinary albumin:creatinine ratio >300mg/mmol; or a new diagnosis of GFR category G5 (GFR <15 mL/min/1.73 m²). Clinicians should seek specialist advice if the urgency of referral is unclear. Renal ultrasound should be performed if the result might change immediate management, for example, in patients with accelerated progression of CKD, visible or persistent invisible haematuria, symptoms of urinary tract obstruction or a nephrologist has identified an urgent need for renal biopsy. Patients who will be starting dialysis should have procedures to establish vascular or peritoneal access.[133]

Patients who have stable renal function may be able to increase the interval between blood and urine testing, depending on comorbidities and whether their CKD is progressive. Clinicians should encourage self-monitoring and self-management where patients are able to do so, for example, patients may monitor their blood pressure at home and access parts of their medical record online. If patients are self-monitoring or self-management, they should receive clear instructions on when to seek help and who to contact. Non-urgent referrals, for example, patients with mild to moderate proteinuria and a stable GFR, may be delayed to reduce risk from COVID-19. Renal ultrasound may be deferred if the result is unlikely to change management immediately, for example, exclusion of polycystic kidney disease in patients with a family history of the condition, if a nephrologist has identified a possible need for non-urgent renal biopsy or the patient has a GFR of <30 mL/min/1.73m² that has been stable for at least 6 months.[133]

Patients who receive haemodialysis are at increased risk of becoming infected with COVID-19 and are at higher risk of severe illness.[134]

US and international guidelines recommend that patients with fever or respiratory symptoms should be asked to contact the unit before arrival and should be isolated and tested for COVID-19 on arrival.[135][136] Each patient should have their temperature monitored on arrival. Patients should wear a cloth face covering while in the facility. If they are not wearing their own on arrival, they should be offered a cloth face covering or face mask as supplies allow.[136]

UK guidelines recommend that patients should be screened before each episode of dialysis to assess whether they are known or suspected to have COVID-19, or have been in contact with someone who has confirmed COVID-19. Patients who might have COVID-19 should be tested, ideally using a rapid turnaround test. They should be assessed for alternative causes for their symptoms and whether dialysis could be delayed until their test results are known.[105]

US guidelines advise that a distance of 6 feet should be maintained between patients in the waiting area and during dialysis. Patients may prefer to wait in their vehicle and receive a message when it is their turn to enter the dialysis unit.[105][136]

Patients with fever should receive dialysis in the last shift of the day until COVID-19 infection is excluded.[135] Consideration should be given to cohorting patients with suspected or confirmed COVID-19 with the same healthcare professional, in the same section of the unit, at the same time.[136] UK guidelines recommend that patients should receive dialysis in cohorts, according to their COVID-19 status. If a patient tests positive for COVID-19, they should remain in that cohort for 7 days or until their symptoms resolve, whichever is the longer.[105]

Healthcare professionals caring for patients with COVID-19 should follow recommended infection control precautions. The Centers for Disease Control and Prevention (CDC) recommends standard, contact, and droplet precautions.[105][136]

UK guidelines advise clinicians to consider the use of potassium binders, such as patiromer or sodium zirconium cyclosilicate, to treat hyperkalaemia or support delaying the start of dialysis.[105] Patients who receive home dialysis and their carers and assistants should be tested if they develop symptoms.[105]

Kidney transplant recipients are at higher risk of severe illness.[132] They are advised to take particularly strict infection prevention and social distancing precautions.

UK guidelines advise clinicians to refer patients for renal transplant where indicated, but explain that some of the tests and assessments may be delayed during the COVID-19 pandemic.[133]

The American Society of Hematology recommends postponing treatment initiation for chronic lymphocytic leukaemia (CLL) in areas where COVID-19 is active. If immediate therapy is needed, treatments that can be provided in an outpatient setting with fewer clinic visits are preferred. Treatment with monoclonal antibodies should be avoided, especially in combination with targeted agents, and initiation of venetoclax should be avoided if possible.[137] Immunoglobulin replacement may be continued in highly selected patients where the potential benefits are outweighed by the risks of visiting a clinic for the infusion. Intravenous immunoglobulin can be continued in those who have COVID-19, but requires close monitoring for thromboembolic events. Patients who are already receiving treatment for CLL and have COVID-19 with mild symptoms should generally not have their treatment modified. Treatment may be modified in patients with more severe symptoms depending on the aggressiveness of CLL, history of infections, and the risk of more severe COVID complications; decisions are made on a case-by-case basis, but generally monoclonal antibodies are withheld in patients with COVID-19.[137]

The American Society of Hematology and the European Hematology Association have published recommendations on the management of chronic myelogenous leukaemia (CML) during the COVID-19 pandemic.[108][138] Treatment with tyrosine kinase inhibitors (TKI) is not immunosuppressive and should not be interrupted in patients receiving treatment, or delayed in those with newly diagnosed CML. If patients are in treatment-free remission but have discontinued TKI therapy for less than 6 to 12 months and do not have access to regular monitoring, the option of postponing discontinuation and re-starting TKI therapy should be discussed. Patients in the chronic phase of CML are not at higher risk of COVID-19 infection, and those that do have COVID-19 infection may not be at higher risk of more severe disease except if they have severe cytopenia on TKI therapy, or active TKI-induced hypersensitivity pneumonitis or other forms of lung damage. Note that all TKI may prolong the QTc interval and strongly interact with potential COVID-19 therapies, such as chloroquine and azithromycin.

Patients with COPD are at higher risk for severe COVID-19 illness and should carefully follow public health advice.

National and international respiratory organisations advise that patients should maintain their regular treatment and that there is currently no evidence to recommend avoiding corticosteroids (inhaled or oral) in patients with COPD during the COVID-19 pandemic.[139][119][120]

UK guidelines also advise that patients established on inhaled corticosteroids should delay any planned withdrawal.[140]

Exacerbations of COPD should be managed by the patient following their individualised plan, and there should be no change to advance prescribing of rescue antibiotics and corticosteroids. Patients should not start rescue antibiotics and corticosteroids to treat symptoms of COVID-19, and should not start prophylactic antibiotics to reduce risk.[140][141] Canadian guidelines recommend that patients with COPD who develop COVID-19 should continue their usual inhaled maintenance therapy and that acute exacerbations of COPD should be treated with prednisolone if needed, irrespective of whether the exacerbation is triggered by severe acute respiratory disease coronavirus 2 (SARS-CoV-2).[118] Patients already taking prophylactic antibiotics should continue to take them as prescribed (unless there is a new reason to stop, such as side effects).[140]

To reduce the risk of acute exacerbations, and a poorer outcome from COVID-19 infection, strongly encourage patients who are still smoking to stop.[140][141]

Patients receiving oxygen therapy should continue as advised, and those using airway clearance techniques should also continue but should take additional precautions to protect family members, as inducing sputum may generate infectious aerosols.[140] Precautions are also advised for those receiving non-invasive ventilation at home, as this is also a potentially infectious aerosol-generating procedure.[140] UK guidelines advise that nebulisation is not considered a viral aerosol-generating procedure and may continue to be used, as the aerosol comes from the fluid in the nebuliser chamber and will not carry virus particles from the patient.[140] However, the Global Initiative for Asthma (GINA) does consider nebulisation to have aerosol-generating potential - see Asthma, above.[116] The US Centers for Disease Control and Prevention advises that nebuliser administration may generate infectious aerosols, however it is unclear whether association between nebuliser administration and infection is due to the generation of infectious particles or the close contact between the patient and healthcare professional administering the nebuliser.[121]

The British Thoracic Society has developed online pulmonary rehabilitation resources for patients to use while face-to-face meetings are not possible.[142]

A panel of experts from North America and Europe has developed recommendations to guide management of chronic pain during the pandemic.[143] The panel recommend the use of telemedicine as the first approach and exclusively in most cases. Opioids may continue to be prescribed or initiated and patients should be informed of the potential risks and impact of long-term opioid use on the immune system. Patients who regularly use non-steroidal anti-inflammatory drugs should continue, while being monitored for adverse effects, and patients should promptly report any mild fever or new myalgia. Use of corticosteroids increases the potential for adrenal insufficiency and altered immune response; clinicians should consider the risks and benefits of corticosteroid injections and use a decreased dose.[143] Insertion of new intrathecal pumps should be avoided, except for highly selected cancer patients where the benefit outweighs the risk. New neurostimulator trials or implants should also be avoided.

Patients with chronic liver disease have a higher mortality rate from COVID-19 infection, and mortality is associated with liver disease severity.[25] European guidelines advise that patients who have cirrhosis and COVID-19 should be admitted to hospital for inpatient care. Patients with cirrhosis and portal hypertension should avoid non-steroidal anti-inflammatory drugs. Care should be taken to avoid paracetamol overdosing in patients with cirrhosis.[144] Guidelines to prevent complications should be followed for patients with decompensated cirrhosis. Vaccination against Streptococcus pneumoniae and influenza is recommended. Treatment for complications (e.g., spontaneous bacterial peritonitis, hepatic encephalopathy, ascites) should be continued.[144] Organ donations and transplants are likely to be reduced in many countries. Listing for transplantation should be restricted to patients with poor short-term prognosis, including those with acute-on-chronic liver failure or a high model for end-stage liver disease (MELD) score.[144]

Transient elastography may reduce the need for endoscopic screening for varices in some patients with cirrhosis. Non-invasive assessments including the Baveno VI criteria, platelet-to-liver stiffness measurement ratio, liver stiffness measurement and spleen stiffness measurement have good predictive value for clinically significant varices and to identify patients at risk of bleeding. Screening for varices should balance the risks of severe acute respiratory disease coronavirus 2 (SARS-CoV-2) transmission from endoscopy against the risk of bleeding. Elective upper gastrointestinal endoscopy to screen for varices in patients with no history of bleeding can be deferred until the COVID-19 outbreak is controlled. Endoscopic eradication of oesophageal varices should be performed following a variceal bleed.[30]

As there is a potential risk of transmission of severe acute respiratory disease coronavirus 2 (SARS-CoV-2) via faecal microbiota transplantation (FMT), the US Food and Drug Administration (FDA) has made the following new recommendations for stool donated after 1 December 2019:[145]

  • Screen donors to identify those who may be currently or recently infected with SARS-CoV-2.

  • Test donors and/or donor stool for SARS-CoV-2, if possible.

  • Patients should give informed consent after being advised about the potential risk of transmission of SARS-CoV-2 via FMT.

Stool used for FMT should have been donated before 1 December 2019 if these criteria are not met.

Community-acquired COVID-19 pneumonia can be difficult to distinguish clinically from community-acquired bacterial pneumonia. UK guidelines advise that COVID-19 pneumonia is more likely if the patient has had typical COVID-19 symptoms for about 1 week, has myalgia or anosmia, has dyspnoea but no pleuritic pain, and has a history of exposure to known or suspected COVID-19. Patients with bacterial pneumonia tend to become rapidly unwell after a few days of symptoms, have pleuritic pain or purulent sputum, and do not have a history of exposure to known or suspected COVID-19. The CRB65 tool has not been validated in patients with COVID-19.[146]

There are no validated tests for assessing dyspnoea by telephone or video consultation.[147] UK guidelines recommend that you should assess the need for hospital admission based on the patient's symptoms and signs. Indicators of more severe illness include: severe shortness of breath at rest or difficulty breathing; haemoptysis; cyanosis; cold, clammy, pale, or mottled skin; syncope; new confusion or difficult to rouse; and little or no urine output.[146]

Antibiotics should not be offered in the community for likely COVID-19 pneumonia when symptoms are mild. If a patient is suitable for oral treatment in the community and it is unclear whether symptoms are bacterial or viral, or the patient is at high risk of complications, antibiotic monotherapy may be prescribed.[146]

Patients admitted to hospital with moderate to severe community-acquired pneumonia may require antibiotic treatment. Tests including culture and sensitivity, severe acute respiratory disease coronavirus 2 (SARS-CoV-2) polymerase chain reaction, chest imaging, full blood count, and legionella and pneumococcal antigen tests are recommended to help guide decisions about antibiotic use.[148] UK guidelines state that if there is confidence that the clinical features are typical for COVID-19, then it is reasonable not to start antibiotic treatment. However, empirical antibiotics should be started if there is clinical suspicion of bacterial infection, including characteristic symptoms and localised chest findings. [148] World Health Organization guidelines advise that antibiotics should not be prescribed for patients with mild COVID-19 and should only be prescribed for patients moderate COVID-19 if there is clinical suspicion of a bacterial infection.[12] Antibiotic treatment should be started within 4 hours of diagnosis and within 1 hour if the patient has suspected sepsis.[148] Choice of antibiotic will depend on local resistance data and availability. If antibiotic treatment was started in the community, this should be reviewed and amended if necessary. Specialist advice on antibiotic choice is recommended for patients who are immunocompromised, pregnant, in critical care, or who have a history of infection with resistant organisms or repeated infective exacerbations of lung disease. Use of antibiotics should be reviewed at 24-48 hours, or when test results are available. Antibiotic treatment may be safely stopped if signs, symptoms, and test results are consistent with COVID-19 pneumonia and there is no evidence of bacterial infection. If antibiotic treatment is continued, the choice should continue to be monitored and reviewed.[148] Patients should be reassessed if they do not improve as expected, or if symptoms become significantly or rapidly worse; specialist advice may be needed.[148] Where possible, clinicians should discuss the benefits, risks, and likely outcomes of any treatment with the patients, their relatives, and carers. The patient's preference about treatment and escalation plans should be sought, and clinicians should enquire about any advance care plans, advance decisions to refuse treatment, or 'do not attempt resuscitation' decisions.

People with congenital heart disease (CHD) may be at increased risk for more severe COVID-19 infection, particularly those with more severe anatomical and physiological features of CHD.[149] Additional considerations for management have been recommended during the current pandemic with strategies for prevention and management of COVID-19 in adults with CHD based on risk stratification.[150] For example, patients in the low risk category (e.g., those with normal ventricular function, normal exercise capacity, no relevant arrhythmia, no pulmonary hypertension) can be advised to take general prevention measures against COVID-19. Low risk patients with mild COVID-19 infection may be cared for at home with remote follow-up, but there should still be a low threshold for hospital admission if there is deterioration/progression or dyspnoea. Adults with CHD in the high risk category (e.g., those with cyanotic conditions, univentricular palliated conditions, severe stenosis or regurgitation, severe ventricular dysfunction, or pulmonary arterial hypertension) are advised to follow stricter prevention measures, such as physical distancing. High risk patients with COVID-19 infection generally require hospital admission and involvement of a CHD specialist.

It is recommended that cardiac medications, including aspirin, ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers, diuretics, and antiarrhythmic medications are continued during COVID-19 illness, unless there is a clear contraindication.[149] Clinicians should be aware of the QT-prolonging effects of some COVID-19 medications (e.g., chloroquine or hydroxychloroquine, azithromycin, lopinavir/ritonavir).

The American College of Obstetrics and Gynecology recommends giving prescription refills for as long as possible to reduce the need for pharmacy visits.[11] UK guidelines advise that a 6- to 12-month course of combined hormonal contraception can be provided without re-checking body mass index and blood pressure.

A 12-month course of a progestogen-only pill can be issued without a face-to-face review.[151]

Users of depot medroxyprogesterone may be offered ongoing contraception with desogestrel (if it is available as a progestogen-only pill).

Routine removals of long-acting contraception should be postponed and users counselled on contraceptive efficacy past the duration of licensed use.[11][151]

Many new patients can be safely screened and offered a prescription for contraception remotely.[11]

UK guidance recommends that patients who wish to start contraception may be assessed remotely and offered a 6- to 12-month course of desogestrel (as a progestogen-only pill). If desogestrel is not suitable, complete remote assessment of medical eligibility and accurate self-reported blood pressure and body mass index is needed to prescribe combined hormonal contraception.[151]

Self-administered oral contraception may be offered as a bridge when insertion of long-acting reversible contraception is delayed due to the COVID-19 outbreak.[11]

Provision of long-acting reversible contraception for women who cannot tolerate oral contraception or who take teratogenic drugs should adhere to local infection control protocols.[151]

The American College of Obstetricians and Gynecologists recommends that women should be counselled on the use of emergency contraception, including over-the-counter and prescription options. Clinicians may consider providing advanced prescriptions for emergency contraception, particularly ulipristal.[11]

The Faculty of Sexual and Reproductive Healthcare in the UK recommends that a copper intrauterine device (Cu-IUD) should continue to be offered as first-line emergency contraception, where possible, to eligible patients. If Cu-IUD provision is delayed, additional oral emergency contraception should be offered. If a Cu-IUD is unsuitable or declined, clinicians should perform a remote assessment to determine the most suitable oral emergency contraception. In addition to this, clinicians should prescribe 3 months' supply of desogestrel (as a progestogen-only pill) and provide clear instructions about starting contraception and taking a pregnancy test.[151]

Contraception - termination of pregnancy

US and UK guidelines emphasise that timely access to abortion should not be compromised during the COVID-19 outbreak. The American College of Obstetricians and Gynecologists (ACOG) advises that gestational age can be assessed remotely for women who have regular periods, a known last menstrual period, and no risk factors for ectopic pregnancy.[11] Assessment, consent, and follow-up can be performed remotely, and medication for medical abortion can be self-administered at home.[11][152] ACOG advises that there is a low risk of rhesus isoimmunisation during a medical abortion; rhesus testing and administration of anti-D immunoglobulin should not be a barrier to provision.[11]

Patients should be advised to continue their current medications. UK guidelines recommend assessing whether patients receiving intravenous treatment can be switched to the same treatment in subcutaneous form, or if this is not possible, to consider an alternative subcutaneous treatment option.[153] Medication should only be stopped or reduced in discussion with a specialist. Preventing disease flares is a priority, to reduce the risk of corticosteroid use and hospitalisation.[154] Patients may continue taking aminosalicylates; these drugs do not affect the immune response.[24] Patients receiving immunosuppressive medication may develop atypical symptoms of COVID-19 (e.g., patients who take an oral corticosteroid may not develop fever). Patients who take an oral or rectal corticosteroid should not stop suddenly if they develop COVID-19.[24][153] Patients taking at least 20 mg/day of prednisolone should observe shielding precautions. New courses should be avoided if possible.[154] Urgent specialist advice should be sought before stopping or changing medications that affect the immune response in patients with COVID-19.[24] Patients who are taking long-term corticosteroids may be at risk of adrenal crisis and may require a higher dose if they are diagnosed with COVID-19.[153] Testing for COVID-19 is recommended before starting medication for a presumptive inflammatory bowel disease (IBD) flare, because COVID-19 can present with gastrointestinal symptoms and administration of higher-dose corticosteroids to these patients could be detrimental.[155] Testing for COVID-19 is also recommended before initiating biologicals, although where possible, initiation should be postponed.[156]

Blood tests to monitor response to therapy should be performed at the minimum safe frequency.[153][154]

International guidelines recommend that patients should stop taking methotrexate, thiopurines, or tofacitinib if they develop COVID-19. Detailed recommendations are given depending on the level of inflammatory bowel disease activity and severity of COVID-19 infection.[157]

If a patient has stopped taking their IBD medication because they have COVID-19, medication can be re-started when at least 10 days have elapsed since symptom onset and at least 3 days have elapsed since recovery. Recovery is defined as the resolution of fever, without use of antipyretics, and an improvement in respiratory symptoms. In patients with severe or critical COVID-19, restarting medication 7-14 days after recovery may be appropriate, depending on the severity of their IBD. If a patient has laboratory confirmed severe acute respiratory disease coronavirus 2 (SARS-CoV-2) infection but has not had symptoms, IBD medication can be restarted 10 days after the first test, providing that no symptoms have developed in the interim.[158] Viral shedding may persist after recovery, particularly in immunocompromised patients, therefore experts recommend making decisions to restart medication based on symptoms rather than repeat testing.[158]

Elective endoscopic procedures should be deferred, but urgent or emergent endoscopy should continue. This includes cases of IBD where endoscopy would urgently change management: for example, establishing the diagnosis in a patient with signs of moderate to severe inflammation, investigating subacute obstruction if imaging suggests a fibrotic or neoplastic stricture, and therapeutic endoscopic retrograde cholangiopancreatography in patients with primary sclerosing cholangitis who have worsening cholangitis and jaundice.[159][160] International guidelines recommend that surgical management of IBD should be considered in some patients, as delay may result in significant downstream morbidity and mortality; decisions on surgery should be individualised for each patient with a multidisciplinary team.[161]

Management of Cushing syndrome is complex and recommendations for clinical practice during the COVID-19 pandemic have been developed by an international group of experts.[162] They advise that patients with active Cushing syndrome are immunosuppressed, and should follow public health advice to minimise their risk of infection. Diagnosis of Cushing syndrome is considered to be challenging at all times, and during the pandemic the guidance recommends prioritising those with key clinical features, investigating those for whom diagnosis is more likely. Patients with moderate and severe clinical disease require urgent investigation and management as they are prone to developing comorbidities that require hospitalisation and have immunosuppression that may make them vulnerable to infection. Investigation should be deferred if clinical features are mild or in doubt; however, treatment of comorbidities such as diabetes and hypertension should be optimised.[162] The guidelines recommend avoiding salivary cortisol/cortisone tests due to potential for viral contamination, until it is known how long severe acute respiratory disease coronavirus 2 (SARS-CoV-2) remains infectious in salivary samples. The usual approach to investigating the cause of Cushing syndrome is significantly modified: immediate computed tomography (CT) scan of thorax, abdomen, and pelvis should be done once Cushing syndrome is confirmed or highly likely to identify cancer, the source of ectopic adrenocorticotrophic hormone syndrome, and any major comorbidities; the presence of Cushing disease can be predicted using a combination of clinical factors, such as age, onset of symptoms, and increases in urinary free cortisol and adrenocorticotrophic hormone; pituitary imaging by magnetic resonance imaging or CT should be done if there is visual field compromise or severe headaches; all other investigations should usually be avoided during periods of high SARS-CoV-2 viral prevalence as they will not affect specific management.[162] The guidelines recommend that surgery for Cushing syndrome is avoided or altered during periods of high SARS-CoV-2 viral prevalence. Comorbidities should be treated with medical therapy as standard. The guidelines recommend avoiding initiating ACE inhibitors or angiotensin-II receptor antagonists for treatment of hypertension until their influence on susceptibility to SARS-CoV-2 infection is clarified; however, patients established on these should continue. Most patients will have steroidogenesis inhibitors. Patients with severe Cushing syndrome should receive prophylaxis for Pneumocystis jirovecii; symptoms of COVID-19 may be similar to infections such as Pneumocystis jirovecii pneumonia, and differentiation is needed to ensure appropriate treatment.[162]

Patients with cystic fibrosis (CF) are at higher risk for severe COVID-19 illness and should carefully follow public health advice.

UK guidance advises that patients and their families and carers should continue with all usual self-care, including airway clearance, regular medication, and home exercise. Exacerbations should be managed as previously advised, including taking rescue medication and contacting their CF team.[163]

If the patient is known or suspected to have COVID-19, airway clearance should be done in a well-ventilated room, separate from other people if possible, as it is a potentially infectious aerosol-generating procedure.[163]

UK guidelines advise that nebulisers will not generate infectious aerosols, as the aerosol comes from fluid in the nebuliser chamber, not the patient, so may be used as normal; however, carers should use appropriate hand hygiene when helping patients with masks.[163] However, the Global Initiative for Asthma (GINA) does consider nebulisation to have aerosol-generating potential - see Asthma, above.[116] The US Centers for Disease Control and Prevention advises that nebuliser administration may generate infectious aerosols; however, it is unclear whether association between nebuliser administration and infection is due to the generation of infectious particles or the close contact between the patient and healthcare professional administering the nebuliser.[121]

Patients are managed remotely where possible. Lung function tests should only be done in hospital if the results will have a direct impact on management; home spirometry should be used where possible.[163]

The European Academy of Neurology has published advice for healthcare professionals who look after patients with dementia.[164] Infection with COVID-19 may cause worsening confusion and precipitate delirium. A significant change in daily routine during the pandemic may trigger behavioural disturbances, and patients with dementia may be less able to comply with infection prevention measures such as washing hands or wearing a face covering. The following measures may be helpful: looking at old photographs, objects, or newspaper clippings, singing old songs, keeping to a regular schedule, simple exercise such as climbing a flight of stairs, using lighting appropriate to the time of day, going outside to orient a person to the time of day, assisting with hand hygiene, facilitating telephone and video calls from relatives, asking directly about symptoms of infection, and accounting for an individual's cognitive impairment when explaining the pandemic.

Further resources are available at:

Patients with diabetes are considered to be at higher risk for severe illness.[132] They are more likely to need intensive care if they develop COVID-19, compared with patients who do not have diabetes, and have a higher case fatality rate.[165][166] Patients with COVID-19 infection appear to have a greater risk of hyperglycaemia with ketones, including patients with newly diagnosed diabetes. COVID-19 disease can precipitate atypical presentations of diabetes emergencies (e.g., mixed diabetic ketoacidosis and hyperosmolar states).[167]

UK guidance advises checking blood glucose and ketones in all patients with diabetes who are admitted to hospital.[167] Out of hospital, patients should follow their usual sick day rules, taking care to continue insulin, remain hydrated, and monitor blood glucose and ketones as appropriate.[168][169] Clinicians may need to prescribe additional blood glucose and ketone testing equipment to support increased monitoring. Patients admitted to intensive care may have insulin resistance and increased insulin requirements. There is a risk of hypoglycaemia if feeding is interrupted (e.g., if the patient is nursed prone).[167] Specialist advice may be needed, particularly for patients who have severe illness on admission or if infusion pumps for insulin are not available.[167]

A panel of international experts has published practical recommendations for the management of diabetes in patients with COVID-19.[170] They advise that those with diabetes who have not been infected with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) should intensify their metabolic control as a measure to prevent COVID-19 infection, including blood pressure and lipid control, and patients should reduce their risk of exposure by having remote healthcare consultations where possible and following public health advice on hand hygiene and physical distancing. The panel recommends that patients with diabetes and COVID-19 require continuous and reliable glycaemic control and that they continue antihypertensive and lipid-lowering treatments. The panel also advises that patients without diabetes are monitored for new-onset diabetes triggered by SARS-CoV-2 infection, particularly those at high risk for metabolic disease. People with type 1 diabetes are more susceptible to infection and require more intensive monitoring and supportive therapy to reduce the risk of metabolic decompensation, including diabetic ketoacidosis; the panel advised that patients are made aware of this and reminded about typical symptoms, home-measurement of urine or blood ketones, sick day rules, and seeking medical advice early if concerned.

Further diabetes resources are available at:

Patients with diabetes are considered to be at higher risk for severe illness.[132] They are more likely to need intensive care if they develop COVID-19, compared with patients who do not have diabetes, and have a higher case fatality rate.[165][166] Older age and elevated C-reactive protein are associated with higher mortality in patients with diabetes. Use of insulin is associated with poor prognosis (progression to severe or critical illness and in-hospital death).[171] Patients with COVID-19 infection appear to have a greater risk of hyperglycaemia with ketones, including patients with type 2 diabetes and those with newly diagnosed diabetes. COVID-19 disease can precipitate atypical presentations of diabetes emergencies (e.g., mixed diabetic ketoacidosis and hyperosmolar states).[167]

Patients taking sodium-glucose co-transporter-2 (SGLT2) inhibitors should be advised to stop these if they become unwell, to reduce their risk of developing diabetic ketoacidosis.[170] Metformin may need to be temporarily stopped if patients are at risk of dehydration.[169][170] UK guidance advises stopping SGLT2 inhibitors and metformin in all patients admitted to hospital.[167] Blood glucose and ketones should be checked in all patients with diabetes who are admitted to hospital.[167]

Patients should follow their usual sick day rules, taking care to continue insulin, remain hydrated, and monitor blood glucose and ketones as appropriate.[168][169] Clinicians may need to prescribe additional blood glucose and ketone testing equipment to support increased monitoring. Patients admitted to intensive care may have insulin resistance and increased insulin requirements. There is a risk of hypoglycaemia if feeding is interrupted (e.g., if the patient is nursed prone).[167] Specialist advice may be needed, particularly for patients who have severe illness on admission or if infusion pumps for insulin are not available.[167]

A panel of international experts has published practical recommendations for the management of diabetes in patients with COVID-19.[170] They advise that those with diabetes who have not been infected with severe acute respiratory disease coronavirus 2 (SARS-CoV-2) should intensify their metabolic control as a measure to prevent COVID-19 infection, including blood pressure and lipid control, and patients should reduce their risk of exposure by having remote healthcare consultations where possible and following public health advice on hand hygiene and physical distancing. The panel recommends that patients with diabetes and COVID-19 require continuous and reliable glycaemic control and that they continue antihypertensive and lipid-lowering treatments. The panel also advises that patients without diabetes are monitored for new-onset diabetes triggered by SARS-CoV-2 infection, particularly those at high risk for metabolic disease. People with type 2 diabetes and comorbid conditions such as obesity and fatty liver disease may be at increased risk for more severe COVID-19 disease, and those with fatty liver disease may be screened for hyperinflammation using trends in laboratory tests to determine where immunosuppression might improve the outcome.

Further diabetes resources are available at:

The British Association of Dermatologists has issued advice to patients with eczema affecting the hands. Patients should adhere to national advice to wash hands with soap and water. Patients should be advised to pat the skin dry and apply emollient generously after handwashing and when the skin feels dry. Patients should be advised that applying emollient before sleep and covering the hands with cotton gloves may help their condition. Patients should protect their hands using gloves if they need to handle detergent for purposes other than handwashing (e.g., washing a child's hair, washing dishes, or cleaning).[172] Patients with facial dermatitis are advised to apply a barrier cream before wearing a face mask and to avoid masks containing metal wires in case of nickel allergy.[112]

For information on managing patients with eczema who take drugs that affect the immune response, please see the section 'considerations for patients with dermatological conditions receiving drugs that affect the immune response' in the introduction to this topic.

The European Academy of Neurology has published advice on the management of epilepsy during the COVID-19 pandemic.[173] Patients with epilepsy should be advised to continue taking their medication, and regular follow-up should continue using telephone or video consultations. Face-to-face appointments should be arranged if required. Fever can trigger seizures in some people with epilepsy, and experts recommend using antipyretics if people with epilepsy develop COVID-19. Coronavirus infection per se is not known to trigger seizures. Patients should be advised to avoid stockpiling medication.[174]

ENT UK has published guidance on the management of epistaxis, aiming to reduce the number of patients admitted to hospital while ensuring safety of patients and staff. Personal protective equipment should be worn, including a level 2 gown, gloves, filtering face-piece (FFP)-3 mask, visor, and hat. Nasal pressure should be applied for 15 minutes and tranexamic acid given. Factors that could promote bleeding, for example elevated blood pressure or use of antiplatelet agents or anticoagulants, should be sought and controlled. A unilateral bioresorbable dressing should be inserted. If the bleeding stops, patients may be discharged from the emergency department with instructions to take 48 hours' bed rest and use a suitable topical antibiotic preparation; if the bleeding does not stop, the patient should be reviewed by an ear, nose, and throat specialist. Silver nitrate cautery and non-absorbable packing should be attempted by a specialist before admitting the patient to hospital.[175]

The British Society for Allergy and Clinical Immunology has recommended modifications to paediatric allergy services during the pandemic. Most new patient and follow-up visits can be performed using telehealth. Allergy testing, and most food challenges, can be deferred. Priority for hospital testing should be given to food challenges where there is a critical nutritional need and it would be unsafe for the parent or carer to perform the food challenges: for example, in infants with milk/soya/hydrolysate food protein enterocolitis syndrome. Where possible, dieticians should contact patients on multiple food exclusions to establish whether food shortages are a concern; additional vitamins, supplements or formulas may be needed. Initiation and updosing of food immunotherapy should be deferred.[176] Sublingual and subcutaneous immunotherapy should be continued as usual in patients who have no symptoms of COVID-19 and have not been exposed to infected individuals within the last 14 days, in patients who have had a negative reverse-transcriptase polymerase chain reaction (RT-PCR) test and in patients who have serum IgG antibodies to severe acute respiratory disease coronavirus 2 (SARS-CoV-2) without virus-specific IgM. Patients who develop COVID-19, have been exposed to infected individuals, or have a positive RT-PCR test should discontinue allergen immunotherapy, independent of disease severity, until symptoms have resolved or adequate quarantine has been performed.[177]

A consensus statement from the Italian Society of Pediatric Allergy and Immunology advises that it may be more difficult for children to access speciality allergy foods during the pandemic, and the potential requirement to try new products increases the risk of an allergic reaction. The society recommends that children have a written action plan with emergency drug doses and have two available adrenaline (epinephrine) autoinjectors.[112]

Haematopoietic stem cell transplantation

UK guidelines advise that for at least 2 weeks before receiving haematopoietic stem cell transplantation (HSCT), patients should follow professional advice on how to minimise their risk of respiratory infection, including COVID-19.[178] All patients receiving HSCT should be tested for respiratory viruses, including severe acute respiratory disease coronavirus 2 (SARS-CoV-2), up to 7 days before admission, and on admission before starting conditioning.[178][179] Patients should also be tested if they have any symptoms of COVID-19. If COVID-19 is confirmed, HSCT should ideally be deferred for 3 months or, if there is a high risk of disease progression, morbidity, or mortality, until the patient is asymptomatic and has had at least two negative SARS-CoV-2 polymerase chain reaction tests. Recommended testing intervals vary between guidelines.[178][179] Patients with confirmed or suspected COVID-19 should have repeat echocardiography, pulmonary function tests, and chest x-ray before starting treatment.[178] UK guidelines advise that for at least 4 weeks before HSCT, donors should follow government advice on social distancing. [178]Donors should be tested at the initial assessment, before stem cells or donor lymphocytes are harvested, and 72 hours before starting conditioning if fresh cell donations are needed. Donors who test positive should defer donations for 3 months after their symptoms resolve; however, if less than 3 months has passed and donation is urgent, this should be referred for risk assessment.[178] If the donor tests positive for COVID-19 on the day of donation after cryopreservation of cells, a shared decision should be made over use of the cells. Donors with known or suspected COVID-19 should not donate other blood products (including lymphocytes) for at least 28 days after symptom resolution.[178]

HSCT should be deferred if possible, particularly for myeloma, low-grade lymphoproliferative conditions, chronic haematological conditions, and non-malignant indications.[178][180]

Following transplantation, patients are at high risk of severe illness and should follow the national recommendations for protecting themselves.[132][178][179] 

Clinicians in Italy have reported assessing patients within 3 months of transplantation and without symptoms of COVID-19 in-person. Patients who are 3 to 24 months post-transplantation may be screened for symptoms of infection or graft-versus-host disease and triaged to in-person or telehealth consultations as appropriate.[181]

Further haematology resources are available at:

European and Asia-Pacific position papers advise that screening for hepatocellular carcinoma (HCC) using ultrasound can be deferred during the COVID-19 pandemic, depending on local resources (including availability of treatment options) and individual patient risk assessment. Patients at highest risk should be prioritised for screening, including patients with: elevated alpha-fetoprotein levels, chronic hepatitis B, advanced cirrhosis, and non-alcoholic steatohepatosis/diabetes.[30][144] HCC surveillance should be deferred until after recovery in patients who develop COVID-19.[144] The European Association for the Study of the Liver recommends that if a patient with HCC develops COVID-19, locoregional therapy should be deferred wherever possible and immune checkpoint inhibitor therapy should be withdrawn. Kinase inhibitors may be continued at a reduced dose; this decision should be made on a case by case basis.[144] The Asia-Pacific Working Group for Liver Derangement during the COVID-19 Pandemic recommends that patients with HCC who have COVID-19 should have treatment for HCC deferred until after recovery from COVID-19. For those who have had surgical resection deferred, bridging transarterial chemoembolisation, radiofrequency ablation, or systemic chemotherapy might be considered in selected patients.[30]

Organ donations and transplants are likely to be reduced in many countries. Listing for transplantation should be restricted to patients at the upper limit of the Milan criteria.[144] Guidelines emphasise the importance of vaccination against Streptococcus pneumoniae and influenza.[144]

Recommendations for the management of patients with primary hepatic malignancies during the COVID-19 pandemic have also been developed by an international group of experts.[182] They propose treatment recommendations for different stages of HCC (according to the Barcelona Clinic Liver Cancer classification system), specifically surgery, locoregional, and systemic therapy, and suggest strategies to modify risk and assist with multidisciplinary treatment decision-making.

There is currently no evidence that the infection rate or disease course of COVID-19 is different in people living with HIV compared with those without HIV infection.[183] However, guidance from the US, UK, and Europe advises that many people living with HIV are older and have comorbid chronic medical conditions such as cardiovascular disease or lung disease, which increase the risk for severe COVID-19 infection. The guidelines recommend that until more is known, additional caution is advised for all people with HIV, especially if advanced (i.e., CD4 cell count <200/microlitre) or poorly controlled. Influenza and pneumococcal vaccinations should be kept up to date.[184][185] US guidelines also recommend that patients maintain at least a 30-day supply of antiretroviral therapy, and ideally a 90-day supply.[184] Advice from the Infectious Diseases Society of America and HIV Medicine Association states that people with HIV have a normal life expectancy and a readily treatable infection, therefore HIV status and current HIV control should not be factors in decision-making regarding potentially life-saving interventions or enrolment into clinical trials. Antiretroviral therapy should be continued in hospital without interruption. Changes in antiretroviral therapy are generally not recommended. Routine viral load monitoring in patients with suppressed HIV and no adherence concerns can be delayed for up to 6 months to reduce the burden on testing laboratories. Viral load testing for patients with adherence concerns or patients whose HIV is not fully suppressed should be prioritised.[186] Pre-exposure prophylaxis to prevent HIV infection should be taken as directed; there is no evidence that it is effective against COVID-19.[187]

Further resources are available at:

A panel of lymphoma experts from the UK has developed interim treatment guidelines for the management of adult patients during the pandemic.[188] Hodgkin's lymphoma is curable in most patients and delivery of dose- and time-intensive treatment remains a high priority; recommendations are given for patients with early-stage and advanced-stage disease, elderly Hodgkin's, relapsed Hodgkin's, and nodular lymphocyte-predominant Hodgkin's.

The American Society of Hematology has also published advice on the treatment of Hodgkin's lymphoma. Chemotherapy followed by interim staging positron emission tomography/computed tomography (PET/CT) is usually preferred to chemotherapy plus radiotherapy for early and advanced-stage disease because fewer hospital visits are needed. The International Lymphoma Radiation Oncology Group has published emergency guidelines for radiotherapy in haematological malignancies, should radiotherapy be necessary. Alternative dose fractionations may be given.[39] Bleomycin should be omitted following a negative PET/CT to reduce the risk of bleomycin pneumonitis. Many experts recommend increased use of granulocyte-colony stimulating factor to reduce neutropenia and use of prophylactic antibiotics when neutropenia is expected. Recommendations are also given for older adult and paediatric patients and those with relapsed or refractory disease.[189] 

Hospital-acquired bacterial pneumonia (defined as developing at least 48 hours after hospital admission and not incubating at admission) can be difficult to distinguish from COVID-19 pneumonia. UK guidelines state that during the COVID-19 pandemic so far, most pneumonia has been viral and that bacterial co-infection occurs in less than 10% of patients with COVID-19, but that bacterial pneumonia may be more likely in patients in critical care wards compared with other hospital settings.[148] Where possible, clinicians should discuss the benefits, risks, and likely outcomes of any treatment with the patients, their relatives, and carers. The patient's preference about treatment and escalation plans should be sought, and clinicians should enquire about any advance care plans, advance decisions to refuse treatment, or 'do not attempt resuscitation' decisions.

Tests including culture and sensitivity, severe acute respiratory disease coronavirus 2 (SARS-CoV-2) polymerase chain reaction, chest imaging, full blood count, and legionella and pneumococcal antigen tests are recommended to help diagnosis and guide decisions about antibiotic use.[148] UK guidelines state that if there is confidence that the clinical features are typical for COVID-19, then it is reasonable not to start antibiotic treatment. However, empirical antibiotics should be started if there is clinical suspicion of bacterial infection, including symptoms and chest findings.[148] World Health Organization guidelines advise that antibiotics should not be prescribed for patients with mild COVID-19 and should only be prescribed for patients with moderate COVID-19 if there is clinical suspicion of a bacterial infection.[12] Antibiotic treatment should be started within 4 hours of diagnosis and within 1 hour if the patient has suspected sepsis.[148]

Choice of antibiotic will depend on local resistance data and availability. Specialist advice on antibiotic choice is recommended for patients who are immunocompromised, pregnant, in critical care, or who have a history of infection with resistant organisms or repeated infective exacerbations of lung disease. Use of antibiotics should be reviewed at 24-48 hours, or when test results are available. Antibiotic treatment may be safely stopped if signs, symptoms, and test results are consistent with COVID-19 pneumonia and there is no evidence of bacterial infection. If antibiotic treatment is continued, the choice should continue to be monitored and reviewed.[148] Patients should be reassessed if they do not improve as expected, or if symptoms become significantly or rapidly worse; specialist advice may be needed.[148]

The UK National Institute of Health and Care Excellence has published guidelines for the management of patients with interstitial lung disease, including idiopathic pulmonary fibrosis, during the pandemic. Many patients with idiopathic pulmonary fibrosis are at risk of severe illness if they develop COVID-19. Patients may have received government advice for protecting people at very high risk ('shielding') and should be advised to follow this advice. Clinicians should discuss with patients whether the benefits of attending medical appointments outweigh the potential risks. Patients should be advised to keep a list of their medications, other medical conditions, and allergies and a copy of a recent clinic letter to give to healthcare staff if they need treatment for COVID-19. Clinicians should determine whether patients have advance care plans or advance decisions to refuse treatment, including 'do not attempt resuscitation' decisions, and take these into account when planning care.[190]

Patients who take drugs that affect the immune response may have atypical presentations of COVID-19; for example, patients taking corticosteroids may not develop fever. Assessment can also be challenging because the symptoms of interstitial lung disease and side effects of medication used to manage the condition may be similar to the symptoms of COVID-19.[190]

Decisions about stopping, adjusting, and re-starting treatment in patients who develop COVID-19 should be made in conjunction with the patient's specialist team. Antifibrotic drugs may be continued if the patient's blood parameters are in the acceptable range and there is no other reason to stop (e.g., significant adverse effects). Clinicians should consider, and discuss with patients, temporarily stopping treatment with immunosuppressants unless the benefits outweigh the risk of aggravating the patient's lung condition. The half-life of some medicines means that the immunosuppressive effect will continue for some time after stopping treatment. Patients who are taking maintenance prednisolone should not stop if they develop COVID-19; they may be at risk of adrenal crisis and require a temporary dose increase if they develop COVID-19. If patients with COVID-19 develop acute kidney injury or deranged liver function tests, medicines should be stopped and adjusted as recommended by your local drug formulary or prescribing information.[190]

New outpatient appointments should be telephone or video appointments if suitable. Unless the patient's condition has altered considerably, blood tests from the past 6 weeks, lung function tests from the past 6 months, and computed tomography scans from the last 12 months can be used to guide diagnosis and treatment. New tests should be performed if these test results are not available but are needed urgently to inform care. In particular, bronchoscopy and lung function testing have the potential to spread COVID-19, so these should only be performed if they are urgent and will directly influence patient care. Patients who require face-to-face appointments should be screened before arrival (by telephone) for symptoms of COVID-19. On arrival, they should be screened for symptoms again and have their temperature checked.[190]

When deciding whether to start or continue an immunosuppressant in patients who do not have COVID-19, clinicians should take into account whether the patient's condition is stable, which treatment has the best risk profile, the likely consequences of delaying the start of treatment, feasibility of monitoring and dose adjustments, frequency and route of treatment, and whether treatment could be reduced or stopped. Patients who are established on immunosuppressive therapy should continue their treatment as prescribed to minimise the risk of their condition worsening. It may be safe to increase the interval between monitoring blood tests if a patient's condition is stable and they have been advised to shield. If the patient's condition is responsive to immunosuppressants and they cannot attend for blood tests, prednisolone alone may be used at the lowest possible dose. Antifibrotic therapy does not increase the risk of getting COVID-19 or make severe disease more likely. Patients who are already taking antifibrotic therapy should continue. Patients with a new diagnosis of idiopathic pulmonary fibrosis may start antifibrotic therapy if a multidisciplinary team confirms the diagnosis, usual eligibility criteria are satisfied, and the appropriate blood monitoring can be performed.[190]

Long-term oxygen assessments should take place in the patient's home, if possible. Assessments may be deferred, according to clinical need, and reassessments may be deferred if the patient’s symptoms are stable. Patients should be referred for lung transplantation according to usual protocols. Patients should be referred for pulmonary rehabilitation or directed to the British Thoracic Society's online pulmonary rehabilitation resources if there are no local services available.[190]

Further resources are available at:

The American Society for Hematology has published advice on management of immune thrombocytopenia (immune thrombocytopenic purpura) during the pandemic. Hospital visits should be minimised and treatment guided by symptom management rather than frequent platelet counts. Treatment should be individualised depending on: urgency of need to increase the platelet count, amount of bleeding, comorbidities, minimising exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and usual practice. Most patients with immune thrombocytopenia do not experience severe bleeding with platelet counts above 10,000-20,000/microlitre, in the absence of comorbidities. Intravenous immunoglobulin (IVIG) or oral thrombopoietic agents (e.g., eltrombopag or avatrombopag) are first line because they are not immunosuppressive. No change to treatment is recommended for patients who are stable on low doses of immunosuppressive drugs. Treatment change may be considered for patients taking higher doses of immunosuppressive drugs or corticosteroids; however, this must be balanced against the increased monitoring requirements and risk of relapse. If indicated, IVIG or oral thrombopoietic agents may allow dose reduction or cessation of immunosuppressive medication or corticosteroids. Rituximab should be avoided.[191]

If a patient with immune thrombocytopenia develops COVID-19, IVIG should be given to maintain the platelet count above 10,000-20,000/microlitre; platelet transfusion should be reserved to treat bleeding or cover procedures with a high bleeding risk. If the patient already takes a thrombopoietic agent, the dose can be increased or a second agent may be started. A short course of corticosteroids to increase platelet count may also be considered. If the patient has had a splenectomy, intravenous antibiotics should be administered until bacterial cultures are documented negative, even if COVID-19 is strongly suspected as the cause.[191]

Patients with COVID-19 may have abnormal liver function tests, including elevated aminotransferases and mildly elevated bilirubin. Low serum albumin on admission to hospital is a marker of COVID-19 severity. Recommendations from the American Association for Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA), and the Asia-Pacific Working Group for Liver Derangement during the COVID-19 Pandemic all advise regular monitoring of liver biochemistries in all hospitalised patients with COVID-19, particularly those treated with remdesivir or tocilizumab, regardless of baseline values.[25][30][192] The Asia-Pacific Working Group advises that while the optimal interval for liver tests is uncertain, it would be reasonable to monitor liver tests twice weekly in patients on potentially hepatotoxic medication and patients with pre-existing liver disease, and more frequently in any patients with abnormal liver function.[30] The AASLD also advises that abnormal liver biochemistries should not be a contraindication to using investigational or off-label therapeutics for COVID-19, although aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels >5 times the upper limit of normal (ULN) may exclude patients from consideration of some investigational agents.[25] The Asia-Pacific Working Group recommends that off-label COVID-19 therapies may be used with caution and close monitoring in those with abnormal liver function; the treatment should be stopped in those with moderate-to-severe liver injury (ie, ALT >5 times ULN or alkaline phosphatase >2 times ULN, and total bilirubin >2 times ULN or presence of coagulopathy or clinical decompensation).[30] Other causes of abnormal liver function tests, including viral hepatitides, should be considered in patients with COVID-19 and abnormal liver biochemistries.[30][192] In patients with autoimmune hepatitis or liver transplant recipients who develop COVID-19, suspected disease flare or acute cellular rejection should be confirmed on biopsy.[25] The Asia-Pacific Working Group recommends screening for hepatitis B surface antigen (HBsAg) in patients who are receiving systemic corticosteroids or other potent immunosuppressants for 7 days or longer as COVID-19 therapy. Patients with known hepatitis B virus (HBV) infection should receive antiviral therapy to avoid HBV reactivation and hepatitis flare, and patients who are newly diagnosed with HBV infection at the time of presentation with COVID-19 should be started on antiviral therapy. Use of tenofovir with lopinavir/ritonavir is relatively contraindicated as the concentration of tenofovir might be increased when these drugs are used together.[30] In patients with hepatitis C virus (HCV) infection, concomitant use of a protease inhibitor-containing direct-acting antiviral regimen with lopinavir/ritonavir is contraindicated, as protease inhibitor concentrations may increase when these drugs are used together, risking ALT elevations.[30]

The European Academy of Neurology has published advice on the management of migraine during the COVID-19 pandemic.[193] Patients with migraine should be encouraged to continue managing lifestyle and dietary triggers: for example, stress, diet, alcohol consumption, and sleep. Social isolation, anxiety, and depression may negatively affect medication overuse, and medications for treatment of acute migraine should be limited to less than two times per week. Non-steroidal anti-inflammatory drugs should be used as needed: they have established efficacy in the treatment of acute migraine, and there is no evidence that they can exacerbate symptoms of COVID-19. Paracetamol and triptans may also be used as required for acute attacks. Ongoing care should be delivered using telemedicine where possible.

The American Society of Hematology (ASH) and European Myeloma Network (EMN) advise that patients who have multiple myeloma with active disease need treatment during the COVID-19 pandemic, but this can be adapted for each patient to reduce additional COVID-19 exposure.[180][194] For patients who require treatment, ASH advises giving 6-12 cycles of bortezomib, lenalidomide, and dexamethasone (RVD), followed by lenalidomide maintenance (with the addition of bortezomib every 2 weeks for high-risk patients). Older myeloma patients may start treatment with RVD or daratumumab, lenalidomide, and dexamethasone (DRd) depending on cytogenetic risk and other comorbidities, and if necessary can continue on lenalidomide and dexamethasone (Rd) only after achieving best response.[180]

Patients should continue on maintenance therapy to reduce the risk of relapse. Lenalidomide can be provided for up to 2 months, with telemedicine visits and home phlebotomy as needed. Higher-risk patients on RVD should continue taking RVD, although if appropriate this could be changed to Rd. If a patient develops COVID-19, maintenance therapy should be interrupted until the infection resolves. Haematopoietic stem cell transplantation should be delayed until after the pandemic.[180]

The EMN provides recommendations for transplant-eligible and transplant ineligible patients. Autologous stem cell transplantation should be postponed in patients with standard-risk disease and may be considered in patients with high-risk disease after 6-8 cycles of induction treatment. Either RVD, bortezomib with thalidomide and dexamethasone, (VTD), or daratumumab with VTD are the preferred induction therapies.[194] Patients not eligible for transplant should be given all-oral regimens (e.g., Rd), with the addition of bortezomib or daratumumab considered for patients with high-risk disease or for those without sufficient response to Rd.[194]

The UK Myeloma Forum has released guidance to assist clinical decision making during the COVID-19 pandemic. Newly diagnosed patients with hypercalcaemia, renal impairment, or bone disease should be offered primary treatment. If the patient is eligible for a stem cell transplant, treatment should include bortezomib and dexamethasone with either thalidomide (VTD) or cyclophosphamide (VCD). For patients who are ineligible for a transplant, lenalidomide and dexamethasone should be given for 9 cycles followed by single agent lenalidomide. Patients with clinical relapse should be offered second- and third-line therapy if the expected benefit outweighs the risk. Autologous haematopoietic stem cell transplant should be deferred unless the patient has clinically high-risk disease, in which case clinicians should judge the likelihood of progression without transplant. Allogeneic haematopoietic stem cell transplant should be deferred.[195]

The UK Medicines and Healthcare products Regulatory Agency has agreed temporary modifications to the pregnancy prevention programmes for patients taking thalidomide, lenalidomide, and pomalidomide. A home pregnancy test is sufficient, provided the patient has adequate support and instruction, the test meets the minimum sensitivity requirements and the result is verified by the prescriber. If the clinician deems it appropriate, these medications can be initiated during a remote consultation.[196]

The Association of British Neurologists (ABN) has produced guidance on the use of disease-modifying therapies in patients with multiple sclerosis (MS) during the pandemic.[197] The ABN advises that the effect of disease-modifying therapies on the risk of COVID-19 remains uncertain, and it recommends that patients are counselled on the individual risk of COVID-19 with a therapy, taking into account its duration of action, any comorbidities, and also the potential impact on the efficacy of any future severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccine. Patients should also be informed if use of their treatment means they should be shielding. The guidance provides information on considered level of risk for specific disease-modifying therapies.[197] The US National MS Society also recommends that decisions on the use of disease-modifying therapies are individualised and should consider disease factors, risks and benefits of therapies, and risks associated with COVID-19.[198] The National MS Society recommends that people currently taking disease-modifying therapies should continue, and if they develop symptoms of COVID-19 or test positive, their therapies should be reviewed with someone familiar with their care.

A cohort study of patients with MS found that risk factors for severe forms of COVID-19 were older age, Expanded Disability Severity Scale (EDSS) score, and obesity.[199] The study found no association between use of disease-modifying therapies and severity of COVID-19.

A panel of lymphoma experts from the UK has developed interim treatment guidelines for the management of adult patients during the pandemic.[188] For most patients with aggressive non-Hodgkin's lymphoma subtypes, treatment is delivered with curative intent and this remains the clinical priority. Recommendations are given for patients with Burkitt lymphoma, diffuse large B-cell lymphoma (DLBCL), primary mediastinal B cell lymphoma, central nervous system (CNS) lymphoma, peripheral T cell lymphoma, and relapsed/refractory aggressive lymphoma. For patients with low-grade non-Hodgkin's lymphoma and not requiring immediate treatment, watchful waiting may be considered.

The American Society for Hematology has published advice for the management of aggressive lymphomas. R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone) remains the standard of care for diffuse large B cell lymphoma. For older patients, R-mini-CHOP (a reduced dose regimen) with growth factor support is recommended. Subcutaneous rituximab may be considered for patients who have tolerated a first intravenous dose. Recommendations are also given for double-hit and primary mediastinal B cell lymphomas, patients at higher risk of CNS involvement, and patients with relapsed or refractory disease.[200] The International Lymphoma Radiation Oncology Group has published emergency guidelines for radiotherapy in haematological malignancies, should radiotherapy be necessary. Alternative dose fractionations may be given.[39]

The European Society of Cardiology has published guidance on the diagnosis and management of cardiovascular disease during the COVID-19 pandemic.[201]

Patients presenting with non-ST-elevation acute coronary syndrome should be risk stratified into four groups: very high, high, intermediate, and low risk. Very high-risk patients include patients with cardiogenic shock, haemodynamic instability, recurrent or persistent chest pain refractory to medical therapy, life-threatening arrhythmias, cardiac arrest, mechanical complications of myocardial infarction, acute heart failure, and recurrent intermittent ST-elevation. High-risk patients are those with an established diagnosis of NSTEMI based on cardiac troponins and at least one of: dynamic ST/T changes, or recurrent symptoms.

Testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) should be performed as soon as possible after first medical contact. However, patients who are very high risk require immediate invasive management as per ST-elevation myocardial infarction (STEMI) protocols. High-risk patients should have early intervention (ideally within 24 hours) after their SARS-CoV-2 test results are known. Intermediate- and low-risk patients should initially be managed with non-invasive testing once their SARS-CoV-2 test results are known. Coronary computed tomography angiography (CCTA) is the favoured investigation for intermediate-risk patients where equipment and expertise are available. Non-invasive imaging using CCTA may speed up risk stratification, avoid an invasive approach, and allow early discharge.[201]

Guidelines from Australia and New Zealand state that reliance on troponin measurements to diagnose acute coronary syndrome in patients with COVID-19 can be misleading, and greater emphasis should be given to high risk clinical features: recurrent chest pain, dynamic ECG changes, heart failure, haemodynamic instability, major arrhythmias, and the presence of regional wall motion abnormalities on echocardiography. Invasive investigations should be deferred in stable patients, particularly if they are COVID-19 positive.[85]

A publication from Public Health England reports that evidence from retrospective cohort studies, clinical audits of hospitalised patients with COVID-19, and primary care records suggests that excess weight is associated with an increased risk of a positive COVID-19 test, hospitalisation, advanced levels of treatment (e.g., mechanical ventilation, intensive care), and death. The risks increase progressively with increasing BMI above the healthy range, even after adjustment for potential confounding factors such as demographic and socio-economic factors.[202] The report notes that there is currently no high-quality research on the effects of weight loss on COVID-19, but that the role of excess weight as a risk factor for serious COVID-19 complications warrants further consideration. For those living with obesity, weight loss has been shown to bring general long-term health benefits.

Olfactory loss (anosmia) may be a presenting symptom of COVID-19. The European Rhinologic Society advises against prescribing intranasal or systemic corticosteroids for patients with sudden olfactory loss. Patients should be advised to continue their usual medications, including intranasal corticosteroids prescribed for other indications.[203]

Guidelines from an international group of experts suggest altering the approach to management of osteoporosis during the current pandemic:[204]

  • Zoledronic acid can be delayed for 6 to 9 months during the pandemic.

  • Patients established on 6-monthly denosumab should continue without any delay and self-administration can be considered where appropriate. Pre-treatment checking of serum vitamin D and calcium levels can be waived and empirical treatment with colecalciferol (vitamin D3) can be considered for all patients.

  • Patients established on teriparatide, abaloparatide, or romosozumab should continue; however, periods of discontinuation for many weeks are unlikely to affect the long-term beneficial effects on fracture risk reduction.

  • No new patients should be started on zoledronic acid, teriparatide, abaloparatide, or romosozumab due to the risk of confusion from potential adverse effects of the therapies and symptoms of COVID-19.

  • If not contraindicated, alternative treatment, such as continuing with an oral bisphosphonate, should be considered.

US guidance advises that the denosumab dosing interval can be extended if necessary to minimise healthcare encounters, but should not exceed 8 months.[205]

Patients should be educated on the importance of continuing with calcium and vitamin D through supplements or diet, and lifestyle measures such as regular exercise and healthy diet.

The National Institute for Health and Care Excellence in the UK has published guidelines for managing symptoms at the end of life in the community. Where possible, clinicians should discuss the benefits, risks, and likely outcomes of any treatment with the patients, their relatives, and carers. The patient's preference about treatment and escalation plans should be sought, and clinicians should enquire about any advance care plans, advance decisions to refuse treatment, or 'do not attempt resuscitation' decisions. Patients with COVID-19 can deteriorate rapidly; treatment escalation plans should be put in place as soon as possible.[206][207]

Cough should initially be managed with non-pharmacological measures if possible. Patients should be discouraged from lying on their back because this makes coughing ineffective. Persistent, distressing cough can be managed with opioids.[206][207][208]

If patients have symptomatic fever, paracetamol or a non-steroidal anti-inflammatory drug (NSAID) may be used as antipyretics. If using an NSAID, advise patients to take the lowest effective dose for the shortest period needed to control symptoms. Antipyretics should not be used with the sole aim of reducing body temperature.[206]

Patients with breathlessness should be advised against using a fan, because this could spread infection. Relaxation and breathing techniques, maintaining a cool environment, opening a window or door, and a trial of oxygen (if available) may help ease symptoms of breathlessness. A combination of opioids and benzodiazepines may be considered for patients who have moderate or severe breathlessness, are distressed, and are near the end of life.[206][208] An antiemetic and regular stimulant laxative should be considered concomitantly.

Benzodiazepines may also be considered to manage symptoms of anxiety and agitation.[208] Oral haloperidol may be considered if a patient has delirium.[206][207]

Consider whether the sublingual, rectal, or subcutaneous route is appropriate for administration for medication; this may be easier for relatives or carers to administer if there are fewer healthcare staff.[206] In the UK, hospices and care homes may run a medicines re-use scheme during the COVID-19 pandemic, following a strict standard operating procedure to ensure safety.[209]

Implantable cardiac defibrillators (ICDs) cannot be deactivated remotely. If a patient with an ICD is receiving end of life care, the treating clinical team should secure a magnet to the skin over the ICD where possible, rather than using the programmer.[86]

Further resources are available at:

A UK consensus statement recommends that endoscopic therapy for malignant biliary obstruction, with biopsy or cytology specimen collection if indicated, should continue during the COVID-19 pandemic. Urgent (2 week wait) cancer referrals and endoscopic ultrasound requests should be considered on a case-by-case basis.[210]

Surgery for resectable pancreatic cancer remains the standard of care and should be performed whenever possible. If surgery is not available, systemic anticancer therapy (SACT) or hypofractionated chemoradiotherapy should be offered. Fluorouracil, folinic acid, irinotecan, and oxaliplatin (FOLFIRINOX) is the preferred SACT regimen. Radiotherapy may be given as 35-45 Gy in 5 fractions, depending on centre expertise, or 36 Gy in 15 fractions with concurrent capecitabine.[210] FOLFIRINOX is most appropriate in patients with a good performance status without significant comorbidities. Dose modification, use of prophylactic antibiotics and growth factors and physical distancing measures should be used to reduce the risk of severe COVID-19 infection.

Patients with locally advanced pancreatic cancer are usually treated with upfront SACT, with or without radiotherapy. Hypofractionated radiotherapy or chemoradiotherapy may reduce risk of severe COVID-19 infection and allow a deferral or break from SACT; this should be balanced against the risk of metastasis without upfront chemotherapy. The risks of treatment in patients aged over 80 years are likely to outweigh the benefits. For fit patients with no significant comorbidities, treatment options include four cycles of modified FOLFIRINOX with or without hypofractionated radiotherapy or five cycles of radiotherapy alone.[210]

The median improvement in survival with palliative chemotherapy for metastatic disease is <6 months so the risks of treatment are likely to outweigh the benefits for many patients. The decision to treat should be taken on a case-by-case basis. Early response assessment should be considered, depending on radiology capacity, because this may allow a shorter duration of chemotherapy. A break from chemotherapy may be appropriate for patients with low volume disease or good disease control. Second-line palliative chemotherapy should not be offered.[210]

Patients with Parkinson's disease who are treated with deep brain stimulation (DBS) require ongoing outpatient visits and surgical care and may not tolerate interruption or cessation of therapy, with some experiencing life-threatening DBS-withdrawal syndrome.[211] In the current pandemic, many elective procedures are being deferred; however, practical recommendations are available to guide management of DBS device complications or battery replacement. Patients who are at high risk for severe or life-threatening symptoms or hospitalisation with DBS cessation would be considered the highest priority for DBS replacement; patients at lower risk may be able to have replacement postponed.[211]

Radiation oncologists from the US and the UK have agreed upon recommendations to safely manage patients with prostate cancer during the COVID-19 pandemic. Visits should be conducted as video consultations whenever possible. In most cases, routine measurement of prostate-specific antigen (PSA) following treatment can be safely deferred for ≥3 months. Radiotherapy for very low-, low-, and favourable-intermediate-risk disease may be deferred until pandemic restrictions are lifted (assuming the pandemic wanes over the next 12 months).[212]

Remote telehealth visits should continue for patients with unfavourable-intermediate, high-risk, very high-risk, post-prostatectomy, clinical node-positive, oligometastatic, and low-volume metastatic disease. Androgen deprivation therapy may allow radiotherapy to be deferred. If androgen deprivation therapy cannot be delivered, the benefits of radiotherapy should be weighed against the risk of COVID-19, taking into account the patient's age, comorbidities, and immunosuppression.[212]

If treatment is deemed necessary and the benefits outweigh the risks, the shortest fractionation schedule that has evidence of efficacy and safety should be followed. If treatment needs to be performed during the peak of the pandemic, brachytherapy is not recommended given its reliance on anaesthesia staff and personal protective equipment. Brachytherapy performed with use of local anaesthesia may be a suitable option for those experienced with this method and if resources are available.[212]

The American Society of Hematology advises that normal D-dimer can be used to effectively rule out pulmonary embolism (PE) in patients with COVID-19. Radiological imaging is not necessary if the D-dimer is normal in the context of low pre-test probability. Elevated D-dimer may have many causes, including secondary infection, myocardial infarction, coagulopathy, and renal failure; new symptoms or signs of PE should be sought, and if possible patients should be investigated for PE with computed tomography pulmonary angiogram and/or bilateral compression ultrasonography of the legs. Clinical features that increase the likelihood of PE include symptoms or signs of deep vein thrombosis, unexplained hypotension or tachycardia, unexplained worsening respiratory status, and risk factors for thrombosis. If pulmonary imaging is not feasible to confirm or refute the diagnosis of PE, bilateral compression ultrasonography of the legs, echocardiography, or point-of-care ultrasonography may be considered. These tests may identify thrombus in situ or in transit, but cannot exclude PE if no clot is detected.[213]

Empirical anticoagulation may be given in the following circumstances, if there is no possibility of performing diagnostic imaging studies and there are no contraindications:[213]

  • Intubated patients who suddenly develop clinical and laboratory findings highly consistent with PE. These may include desaturation, tachycardia, increased central venous or pulmonary wedge pressure, or evidence of right heart strain on echocardiogram, particularly if their inflammatory markers and chest radiograph findings are improving.

  • Patients with physical findings consistent with thrombosis, such as superficial thrombophlebitis, peripheral ischaemia or cyanosis, thrombosis of dialysis tubing, or retiform purpura.

  • Patients with respiratory failure in whom PE is highly suspected and other causes are not identified, particularly when D-dimer and/or fibrinogen levels are very high.

Patients who have documented or presumed PE should continue therapeutic anticoagulation for 3 months. Anticoagulation may then cease if the patient has fully recovered from COVID-19 and there are no other risk factors for thrombosis or indications for anticoagulation.[213]

Renal transplant

UK guidelines advise that renal transplant recipients are clinically extremely vulnerable to COVID-19 and should follow government guidance on shielding. Clinicians should consider whether less frequent blood monitoring is appropriate for patients who are stable on immunosuppressive treatment. Patients who take immunosuppressive treatment may present with atypical symptoms and signs of COVID-19; for example, patients taking prednisolone may not develop a fever. Other infectious and non-infectious causes should also be considered in patients who present with respiratory symptoms or fever. If a patient develops COVID-19, clinicians should consider modifying their immunosuppressive treatment.[214] Guidelines from the British Transplantation Society and Renal Association recommend stopping mycophenolate and azathioprine until the patient has fully recovered. If the patient is admitted to hospital, clinicians should consider stopping or reducing calcineurin inhibitors. If the patient is taking corticosteroids, an increase in dose may be considered.[215]

Transplant specialists should discuss the risks and benefits of transplantation with patients. Clinicians should take a history of social distancing and any contact with people who might have COVID-19, take a nasopharyngeal swab for severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2), and conduct a respiratory assessment when patients are admitted to hospital for a transplant. SARS-CoV-2 testing should be interpreted in the context of other assessments; a negative test does not definitely rule out infection. Dialysis in the 14 days preceding the transplant should take place in a COVID-19 secure area.[214]

Transplant recipients should have a negative swab for SARS-CoV-2 before receiving a deceased donor kidney. People who have been exposed to suspected or confirmed COVID-19 in the past 14 days, who have died from unexplained respiratory failure, or who test positive on a polymerase chain reaction test for COVID-19 are not suitable deceased donors.[216]

Live kidney donors and their household should self-isolate for 14 days before the transplant. Live kidney donors and intended transplant recipients should both have negative swabs for SARS-CoV-2 48 to 72 hours before surgery. Donor surgery should not begin until both donor and recipient are confirmed swab-negative for SARS-CoV-2.[217]

If patients on the kidney transplant waiting list develop COVID-19, they should be suspended from the waiting list until they have recovered, been symptom-free for 28 days, and have a negative swab for SARS-CoV-2.[214]

Patients should continue their usual medication and observe recommended infection prevention and control precautions.[218][219] If it is possible and clinically safe, corticosteroid dose may be tapered. Clinicians should consider alternatives to corticosteroids where possible, and if corticosteroids are needed, prescribe the lowest effective dose for the shortest possible time. Corticosteroid injections should only be given when a patient has significant disease activity and/or intrusive and persistent symptoms, and there are no suitable alternatives.[220] UK guidelines recommend assessing whether patients receiving intravenous treatment can be switched to the same treatment in subcutaneous form, or, if this is not possible, to consider an alternative subcutaneous treatment option.[153]

Conventional synthetic disease-modifying antirheumatic drugs (DMARDS) may be started or switched in patients with newly diagnosed or active inflammatory arthritis.[205]

Patients receiving immunosuppressive medication may develop atypical symptoms of COVID-19 (e.g., patients who take an oral corticosteroid may not develop fever). Patients who take an oral corticosteroid should not stop suddenly if they develop COVID-19.[153][205] Patients who are taking long-term corticosteroids may be at risk of adrenal crisis and may require a higher dose if they are diagnosed with COVID-19.[153] Patients may continue taking hydroxychloroquine if they are infected with severe acute respiratory disease coronavirus 2 (SARS-CoV-2), but should stop any other conventional DMARDs or biologicals.[153][205] UK guidelines advise that patients may continue sulfasalazine if they are infected with severe acute respiratory disease coronavirus 2 (SARS-CoV-2).[153] Interleukin-6 receptor inhibitors may be continued in select circumstances as part of a shared decision-making process.[205] The half-life of some drugs means that immunosuppression will continue for some time after stopping treatment.[153]

Patients may continue taking non-steroidal anti-inflammatory drugs (NSAIDs). The Commission of Human Medicines in the UK reviewed the safety of ibuprofen in patients with COVID-19 and concluded that there is currently insufficient evidence to establish a link between use of ibuprofen, or other NSAIDs, and contracting or worsening of COVID-19.[221] The UK National Institute for Health and Care Excellence has also reviewed the evidence to determine if long-term use of NSAIDs is associated with an increased risk of developing COVID-19, or an increased risk of developing more severe COVID-19, and found no evidence to recommend that people taking NSAIDs for a long-term condition should stop, and that stopping or switching NSAID treatment could have a negative impact in some people.[222] The American College of Rheumatology advises stopping NSAIDs in patients who develop COVID-19 and have severe respiratory symptoms.[205]

The US Food and Drug Administration (FDA) is investigating and states: "At this time, FDA is not aware of scientific evidence connecting the use of NSAIDs, like ibuprofen, with worsening COVID-19 symptoms."[223] The European Medicines Agency advises that patients and clinicians can continue using NSAIDs as per the approved product indication, and has highlighted the need for timely epidemiological studies to provide adequate evidence for any effect of NSAIDs on the disease prognosis of COVID-19.[224]

Following recovery from COVID-19, US guidelines recommend that rheumatic disease treatments can be restarted within 7-14 days of symptom resolution in patients with mild or no pneumonia who were treated in the ambulatory setting or with self quarantine. Decisions regarding restarting rheumatic disease therapies in patients who had more severe COVID-19 should be taken on an individual basis. If a patient had a positive polymerase chain reaction test for SARS-CoV-2 but has remained asymptomatic, rheumatic disease treatments may be restarted 10-17 days after the positive test result.[205]

Some patients may experience difficulty obtaining hydroxychloroquine. If a patient cannot obtain hydroxychloroquine, clinicians should consider whether a dose reduction or temporary cessation of hydroxychloroquine is possible.[225] Clinicians should take measures to reduce hospital visits for patients, which may include longer duration of prescriptions, home delivery of medication, utilising telephone or video appointments, and increasing drug monitoring to the maximum safe interval.[153][219]

UK guidelines recommend that patients urgently referred for suspected inflammatory arthritis have a remote consultation first, and then a face-to-face appointment after reviewing for COVID-19 symptoms.[153] Patients are advised to have influenza, whooping cough, and pertussis vaccinations.[226]

Patients with sickle cell disease are at higher risk of severe disease and death if they become infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A registry of patients with sickle cell disease and COVID-19 in the US reported that the rate of hospitalisation amongst adults with sickle cell disease was 69%, the intensive care admission rate was 11% and mortality was 7%.[227] The Sickle Cell Disease Association of America has published advice on reducing sickle cell disease morbidity during the COVID-19 pandemic. Routine consultations should take place via telephone or video wherever possible and should not be cancelled. Patients should be advised to adhere carefully to their usual medication, to use a thermometer at home, and to seek prompt medical advice if they develop fever. Clinicians should ensure that patients have an adequate supply of medication to manage acute and chronic pain, and consider starting or optimising therapies known to reduce acute sickle cell pain frequency to reduce the need for hospital attendance.[228]

Patients who have acute sickle cell pain without fever or signs of infection should be encouraged to manage pain with oral medication at home. Patients should be closely monitored, with a low threshold for arranging a face-to-face evaluation and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing.[228]

Patients with fever, cough, or shortness of breath require immediate evaluation for COVID-19. Care should include an assessment for other sources of infection with culture of blood (and other specimens as indicated), testing for typical viral infections, administering broad-spectrum antibiotics to cover encapsulated organisms, and assessing for acute chest syndrome. If the patient tests negative for SARS-CoV-2, home treatment with oral antibiotics and close monitoring may be appropriate. If possible, patients should be given an incentive spirometer to use at home.[228]

Patients with confirmed COVID-19 should be monitored closely for signs of rapidly progressive acute chest syndrome (thrombocytopenia, acute kidney injury, hepatic dysfunction, altered mental status, and multi-organ failure). The symptoms of acute chest syndrome may overlap significantly with symptoms of COVID-19. Standard care for acute chest syndrome should be given, including supplemental oxygen, empirical antibiotics, oseltamivir until influenza is excluded, incentive spirometry, and good pain control. Patients with worsening anaemia, evidence of hypoxia, and chest x-ray changes should receive a transfusion of red blood cells. Clinicians should consider the possibility of undiagnosed pulmonary hypertension in acutely ill patients and be alert for signs of fat emboli syndrome. Signs of fat emboli syndrome include worsening anaemia and mental status, haemolysis, thrombocytopenia, hypoalbuminemia, respiratory distress, and petechial rash; it may progress quickly and carries a high mortality. Patients who have COVID-19 and are discharged from hospital remain at high risk of secondary bacterial infection and acute chest syndrome; they should be monitored daily.[228]

If availability of blood products is limited, the highest priority indications for chronic transfusion are: stroke prevention, progressive or critical neurovascular disease, recurrent acute chest syndrome unresponsive to hydroxycarbamide, and cardiovascular or respiratory comorbidity. Clinicians should assess whether patients can switch to hydroxycarbamide or whether transfusion strategy can be temporarily altered.[228]

In patients with COVID-19, evidence suggests that smoking is associated with an increased risk of more severe disease and death.[229] People who smoke tobacco may also have an increased risk of contracting COVID-19. It is well-established that smoking damages the lungs and airways, and weakens the immune response; people exposed to second-hand smoke are also at increased risk.

Smoking involves repetitive hand-to-mouth movements, which may increase the risk of infection. Vaping/use of e-cigarettes is often used as nicotine-replacement therapy; however the evidence on benefits and harms is still developing. Vaping also involves repetitive hand-to-mouth movements.[230] Smoking cessation is strongly encouraged.[229][230]

The European Society of Cardiology has published guidance on the diagnosis and management of cardiovascular disease during the COVID-19 pandemic.[201]

The guidance emphasises that the pandemic should not compromise the timely reperfusion of patients with STEMI, therefore in the absence of previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing all patients should be managed as if they are COVID-19 positive. Primary percutaneous coronary intervention (PCI) is the re-perfusion treatment of choice if it can be performed within 120 minutes in appropriate facilities while ensuring the safety of healthcare professionals and other patients. Experience suggests that a delay of up to 60 minutes may occur due to implementing protective measures, and clinicians should take this into account when assessing whether timely primary PCI is possible. If primary PCI cannot be performed within the target time, fibrinolysis is the intervention of choice provided there are no contraindications. All patients should undergo testing for SARS-CoV-2 as soon as possible following first medical contact irrespective of reperfusion strategy, at the latest upon admission to the intensive care unit after primary PCI. Clinicians should consider immediate complete revascularisation, if indicated and appropriate, in order to avoid staged procedures and reduce hospital stay.[201]

Guidance from the American Heart Association/American Stroke Association advises that patients with COVID-19 may present with neurological symptoms (such as dizziness, headache, or encephalopathy) at the same time as, or even preceding, the development of respiratory symptoms and fever. Patients affected by stroke may be unable to give a history of COVID-19 symptoms or exposure owing to confusion or aphasia. Patients with stroke frequently develop a fever from stroke complications, including aspiration pneumonia and urinary tract infection; these patients require rapid evaluation for COVID-19.[231]

Evaluation using telemedicine can allow a timely assessment, reduce inter-provider transfers, and protect healthcare professionals. Ideally, full personal protective equipment should be worn by the assessing healthcare professional, but this may not be possible where there are shortages.[231]

All stroke teams should endeavour to adhere to guidelines for patient selection for therapy, treatment timeframes, and post-recanalisation monitoring. Teams should use their judgement, guided by local circumstances, to treat as many patients with acute stroke as possible. Patients with large intracerebral bleeds, subarachnoid haemorrhage, or large ischaemic strokes at risk of herniation should be monitored in an intensive care setting, with appropriately trained personnel, where possible. Stable patients may be moved out of intensive care to step-down facilities during the 24-hour post-thrombolysis or thrombectomy follow-up period, if an intensive care bed is needed. Stroke physicians should provide guidance to staff if patients with acute stroke have suspected or confirmed COVID-19 and require admission to a COVID-19 unit.[231]

UK guidance recommends that prehospital telemedicine can be used to reduce unnecessary conveyance to hospital for patients with stroke mimics and transient ischaemic attacks. Emergency department assessment of patients who may be suitable for thrombolysis should be performed using telemedicine. Consideration should be given to reducing the need for repeat imaging: clinicians should request a magnetic resonance imaging scan as initial imaging if the patient is likely to need one, and if the patient has carotid territory symptoms, clinicians should consider requesting computed tomography (CT) angiography at the time of the initial CT scan.[232]

Particular attention should be given to trying to maintain the following aspects of the stroke care pathway: assessment by a senior clinician within 1 hour, appropriate cerebral imaging within 1 hour, rapid thrombolysis and referral for thrombectomy, reversal of anticoagulation and blood pressure control in patients with intracerebral haemorrhage within 1 hour, direct admission to stroke unit, early swallow screen, maintaining stroke unit care for as long as needed, and early supported discharge from hospital.[232]

Patients with transient ischaemic attack (TIA) should be assessed using telemedicine, with local access to blood pressure and ECG recording. Patients with TIAs should not be admitted to hospital or kept in the emergency department. Most outpatient reviews can be performed using telemedicine.[232]

Experts have made recommendations to reduce the risk of Strongyloides hyperinfection or dissemination in people at moderate to high risk of Strongyloides infection. There is a risk of hyperinfection following exposure to immunosuppressive drugs. Chronic strongyloidiasis is often asymptomatic; suspicion should be based on risk factors including residence in an endemic area, rural residence, and exposure to soil during labour. A screen-and-treat strategy is recommended for patients at moderate to high risk of Strongyloides infection without confirmed COVID-19, asymptomatic patients with a positive polymerase chain reaction test, and patients with mild COVID-19 who are not candidates for dexamethasone. Serologic testing is preferred. Patients in the hospital setting who are at moderate to high risk of Strongyloides infection, are SARS-CoV-2 positive, and are initiating or are likely candidates for dexamethasone should be treated presumptively with ivermectin. Patients at moderate to high risk of Strongyloides infection who have unexplained gram-negative rod infections after receiving dexamethasone or other immunosuppressive agents should have diagnostic testing for Strongyloides infection. Ivermectin should be given while awaiting results.[233]

Chloroquine and hydroxychloroquine should be started at full dose (when available) for patients with newly diagnosed SLE. Chloroquine and hydroxychloroquine should be continued at the same dose during pregnancy.[205] Some patients may experience difficulty obtaining hydroxychloroquine. If a patient cannot obtain hydroxychloroquine, clinicians should consider whether a dose reduction or temporary cessation of hydroxychloroquine is possible.[225]

Belimumab, ACE inhibitors, angiotensin-II receptor antagonists, and glucocorticoids may be initiated if indicated. High-dose glucocorticoids or immunosuppressants may be initiated for patients with lupus nephritis. Glucocorticoids should not be stopped abruptly and should be used at the lowest possible dose to control disease.[205]

Chloroquine, hydroxychloroquine, and non-steroidal anti-inflammatory drugs (NSAIDs) may be continued following SARS-CoV-2 exposure. In patients with COVID-19, chloroquine and hydroxychloroquine may be continued, regardless of severity. NSAIDs should be stopped in patients with severe respiratory symptoms.[205]

Following recovery from COVID-19, US guidelines recommend that rheumatic disease treatments can be restarted within 7-14 days of symptom resolution in patients with mild or no pneumonia who were treated in the ambulatory setting or with self quarantine. Decisions regarding restarting rheumatic disease therapies in patients who had more severe COVID-19 should be taken on an individual basis. If a patient had a positive polymerase chain reaction test for SARS-CoV-2 but has remained asymptomatic, rheumatic disease treatments may be restarted 10-17 days after the positive test result.[205]

Blood transfusion and luspatercept should be continued as usual. Iron chelation should be continued in well patients. If a patient develops COVID-19 then interruption of iron chelation is usually advisable; the case should be discussed with the patient's haematologist. Febrile, splenectomised patients should be investigated for bacterial infection and receive empirical antibiotics to cover secondary bacterial infections.[234]

Plasma exchange remains the recommended initial treatment for immune-mediated thrombotic thrombocytopenic purpura (iTTP). Corticosteroids and rituximab should still be used in treatment of acute iTTP. Patients with severely deficient ADAMTS13 activity may still receive rituximab to prevent relapse; the potential increased risk of COVID-19 complications should be balanced against the benefit of delaying or preventing relapses of iTTP. If access to plasma exchange is limited, the patient should ideally be transferred to a facility that can offer plasma exchange; otherwise, caplacizumab and immunosuppressive therapy alone may be considered.[235]

If a patient develops COVID-19, plasma exchange should be used in the same way as for other patients; the risks and benefits of corticosteroids and rituximab should be carefully considered. Caplacizumab may be used in conjunction with plasma exchange as a temporising measure to protect from exacerbations and relapses until recovery from COVID-19; after recovery, corticosteroids and/or rituximab may be used to increase ADAMTS13 activity.[235]

Patients should be advised to continue their current medications. UK guidelines recommend assessing whether patients receiving intravenous treatment can be switched to the same treatment in subcutaneous form, or, if this is not possible, to consider an alternative subcutaneous treatment option.[153] Medication should only be stopped or reduced in discussion with a specialist. Preventing disease flares is a priority, to reduce the risk of corticosteroid use and hospitalisation.[154] Patients may continue taking aminosalicylates; these drugs do not affect the immune response.[24]

Patients receiving immunosuppressive medication may develop atypical symptoms of COVID-19 (e.g., patients who take an oral corticosteroid may not develop fever). Patients who take an oral or rectal corticosteroid should not stop suddenly if they develop COVID-19.[24][153] Patients who are taking long-term corticosteroids may be at risk of adrenal crisis and may require a higher dose if they are diagnosed with COVID-19.[153] Patients taking at least 20 mg/day of prednisolone should observe shielding precautions. New courses should be avoided if possible.[154] Urgent specialist advice should be sought before stopping or changing medications that affect the immune response in patients with COVID-19.[24] Testing for COVID-19 is recommended before starting medication for a presumptive inflammatory bowel disease (IBD) flare, because COVID-19 can present with gastrointestinal symptoms and administration of higher-dose corticosteroids to these patients could be detrimental.[155] Testing for COVID-19 is also recommended before initiating biologicals, although where possible, initiation should be postponed.[156]

Blood tests to monitor response to therapy should be performed at the minimum safe frequency.[153][154]

International guidelines recommend that patients stop taking methotrexate, thiopurines, or tofacitinib if they develop COVID-19. Detailed recommendations are given depending on the level of inflammatory bowel disease activity and severity of COVID-19 infection.[157] If a patient has stopped taking their IBD medication because they have COVID-19, medication can be re-started when at least 10 days have elapsed since symptom onset and at least 3 days have elapsed since recovery. Recovery is defined as the resolution of fever, without use of antipyretics, and an improvement in respiratory symptoms. In patients with severe or critical COVID-19, restarting medication 7-14 days after recovery may be appropriate, depending on the severity of their IBD. If a patient has laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection but has not had symptoms, IBD medication can be restarted 10 days after the first test, providing that no symptoms have developed in the interim.[158] Viral shedding may persist after recovery, particularly in immunocompromised patients, therefore experts recommend making decisions to restart medication based on symptoms rather than repeat testing.[158]

Elective endoscopic procedures should be deferred, but urgent or emergent endoscopy should continue. This includes cases of IBD where endoscopy would urgently change management: for example, establishing the diagnosis in a patient with signs of moderate to severe inflammation, diagnosing a severe acute flare of ulcerative colitis, investigating sub-acute obstruction if imaging suggests a fibrotic or neoplastic stricture, and therapeutic endoscopic retrograde cholangiopancreatography in patients with primary sclerosing cholangitis who have worsening cholangitis and jaundice.[159][160] International guidelines recommend that surgical management of IBD should be considered in some patients, as delay may result in significant downstream morbidity and mortality; decisions on surgery should be individualised for each patient with a multidisciplinary team.[161]

COVID-19 may present with gastrointestinal (GI) symptoms that mimic viral gastroenteritis. The estimated pooled prevalence of GI symptoms in patients with COVID-19 varies from less than 10% to 15%.[192][236] Nausea or vomiting, anorexia, and diarrhoea are the most common manifestations.[236] Patients with severe COVID-19 had higher rates of GI symptoms than those with less severe disease. Most patients with GI symptoms and COVID-19 have concomitant respiratory symptoms or fever; 3% of patients reported GI symptoms only.[237] Patients may present with nausea or diarrhoea 1 to 2 days prior to onset of fever and breathing difficulties.[165] A retrospective cohort study found that median duration of viral shedding in stool samples was 22 days, compared with 18 days in respiratory samples and 16 days in serum samples. The median duration of shedding was lower in mild illness (14 days) compared to severe illness (21 days).[238]

Guidelines from the American Gastroenterological Association (AGA) recommend that outpatients with new-onset diarrhoea are asked about high risk contact exposure, whether they have a history of COVID-19-associated symptoms, and whether they have other GI symptoms (nausea, vomiting, abdominal pain).[192] Patients with new-onset GI symptoms should be monitored for symptoms of COVID-19, as GI symptoms may precede other COVID-related symptoms by a few days. Currently, there is not enough evidence to support stool testing for diagnosis or monitoring of COVID-19 as part of routine clinical practice.[192] In hospitalised patients with known or suspected COVID-19, the AGA recommends obtaining a thorough history of GI symptoms, including onset, characteristics, duration, and severity. 

The British Society for Haematology has published guidance on B12 supplementation during the COVID-19 pandemic.

Patients who have B12 deficiency that is not related to diet (e.g., pernicious anaemia, gastrectomy, inflammatory bowel disease, achlorhydria) can omit 1 or 2 quarterly injections, since liver stores of B12 last up to 1 year. Injections should be delayed until the surge of the pandemic has passed. Oral B12 can be offered as an alternative if the patient is symptomatic in the weeks preceding B12 injection.[239]

Patients who have B12 deficiency related to diet should be offered advice on dietary sources of B12. Patients may suspend B12 supplementation during the pandemic because they are B12 replete; patients may also be offered oral B12 supplementation.[239]

Further haematology resources are available at:

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