Summary of COVID-19 medicines guidance: Allergy and immunology

Eimear Maguire, Senior Medicines Information Pharmacist, North West Medicines Information CentrePublished

This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and allergy and immunology conditions.

Our advice is constantly reviewed as the pandemic situation evolves.

Whilst we have tried to ensure that the information on this page is complete, please report a concern if you feel anything is omitted or inaccurate.

To see our professional guidance summaries for other clinical areas, click here

Advice in this area includes:

NICE: COVID-19 rapid guideline: children and young people who are immunocompromised

Last updated 14 August 2020

  • The purpose of this guideline is to maximise the safety of children and young people who are immunocompromised during the COVID-19 pandemic. It also aims to protect staff from infection and enable services to make the best use of NHS resources; it focuses on what you need to stop or start doing during the pandemic.
  • Children and young people who are immunocompromised include those with: primary immunodeficiencies, secondary or acquired immunodeficiencies because of their condition or because of immunosuppressive treatment, chronic disease associated with immune dysfunction (such as organ dysfunction or failure or severe inflammatory disease).
  • Provides advice on managing the underlying condition in patients not known to have COVID-19; for example, management of: patients who are not yet taking medicines that affect the immune system but who may require them; patients who are already taking medicines that affect the immune response; monitoring of patients stabilised on treatment.
  • Provides advice on managing the underlying condition in patients suspected of having COVID-19; for example, patients taking medicines that affect the immune response might have atypical presentations of COVID 19 (e.g. those taking prednisolone may not develop a fever); when deciding about whether to stop usual treatment when a patient has symptoms of COVID 19, contact the specialist team for urgent advice before stopping any medicines.
  • Advises on modifications to usual care, including the supply of medicines.

NICE: COVID 19 rapid evidence summary: Anakinra for COVID-19 associated secondary haemophagocytic lymphohistiocytosis

Last updated 21 May 2020 [Text updated 9 Feb 2021]

  • NICE has produced a rapid evidence summary on the use of Anakinra for COVID-19 associated secondary haemophagocytic lymphohistiocytosis.
  • Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome, which can lead to a cytokine storm, tissue damage and multi-organ failure. It has a high mortality rate. Viral infections are the most common cause of secondary HLH (sHLH).
  • A hyperinflammatory response develops in some people with COVID-19, which may be localised to the lungs or lead to widespread systemic illness and sHLH.
  • Anakinra is recommended (off label) in treatment algorithms for sHLH as part of a multi-disciplinary team decision-making process. In critical illness, subcutaneous absorption can be unreliable and intravenous dosing is sometimes used in clinical practice to achieve a higher and faster maximal plasma concentration (it is not licensed for intravenous administration).
  • No relevant papers were identified in the searches undertaken for this evidence review. Therefore, no evidence is available to determine whether anakinra is effective, safe or cost effective for treating adults and children with sHLH triggered by SARS-CoV-2 or a similar coronavirus.
  • At this time, policy decisions on whether anakinra should be used for treating COVID-19 associated sHLH will need to consider data extrapolated from studies assessing anakinra for related conditions, such as macrophage activation syndrome, non-coronavirus sHLH and hyperinflammation in people with COVID-19 and acute respiratory distress syndrome (ARDS).

Allergy UK: Coronavirus and Allergy – FAQs

Last updated 23 April 2020

Allergy UK has information aimed at patients; it answers FAQs, such as:

  • Do medications for allergic conditions, such as antihistamines and montelukast have a negative effect on immunity?
  • Should medications for asthma or allergy be stopped if the patient has come into contact with a COVID-19 positive individual?
  • Can I keep using steroid nasal sprays?
  • How do get medications (prescription and non-prescription) if self-isolating?

There is also a COVID-19 Vaccination and Allergies FAQ, produced in conjunction with Anaphylaxis Campaign and the BSACI [last updated 4th March 2021, added 22nd December 2020]

Anaphylaxis Campaign: Coronavirus and allergies: Frequently Asked Questions

An FAQ document produced in conjunction with Allergy UK and the British Society for Allergy and Clinical Immunology; it covers:

  • If EpiPens will help respiratory distress caused by coronavirus.
  • If oral steroids or antihistamines for allergic reactions increases the risk from coronavirus.
  • If sublingual or injection immunotherapy for pollen/dust mite/venom allergy should be continued or deferred.
  • If patients who are allergic to paracetamol, anti-inflammatories or antibiotics are at extra risk of coronavirus, if they should be shielding.
  • If patients who have tested positive for COVID-19 should continue their allergy medicines.

There is also a COVID-19 Vaccination and Allergies FAQ, produced in conjunction with Allergy UK and the BSACI [Last updated 3rd March 2021, Added 22nd Dec 2020]

British Society for Allergy and Clinical Immunology: COVID-19 Vaccinations and Allergies FAQ

Last updated 3 March 2021

  • A COVID-19 Vaccination and Allergies FAQ, produced in conjunction with Anaphylaxis Campaign and Allergy UK [added 20th January 2021]

British Society for Allergy and Clinical Immunology: Modifications for adult allergy services during Covid-19 pandemic

Last updated 3 April 2020

This document provides suggestions for changes to adult allergy service provision during the COVID-19 pandemic:

  • Services should ensure patients are provided with adrenaline autoinjectors when appropriate, and have received appropriate education regarding administration.
  • Advice on deferral of subcutaneous immunotherapy (SCIT), sublingual immunotherapy (SLIT) and venom immunotherapy (VIT) in new patients; for current patients, advice on extending the interval between doses, when shorter post-dose observation periods are appropriate and when to consider therapy withdrawal.
  • Information on omalizumab e.g. deferral in new patients, risk of immunosuppression and suitability of home administration.
  • Services should ensure patients taking immunosuppressive medications (e.g. prednisolone, ciclosporin, azathioprine etc) are given appropriate advice with regard to social distancing and shielding according to government advice.

British Society for Allergy and Clinical Immunology: Modifications for paediatric allergy services during Covid-19 pandemic

Last updated 24 March 2020

This document provides suggestions for changes to paediatric allergy service provision during the COVID-19 pandemic:

  • Do not ‘step down’ preventer medication in patients with asthma during the COVID-19 pandemic, unless this is clearly favourable for an individual patient.
  • Do not initiate sublingual or subcutaneous immunotherapy in children with allergic rhinitis unless there are exceptional circumstances, such as unavoidable exposure to a trigger resulting in anaphylaxis. Children already started on sublingual immunotherapy should continue their treatment with review via telephone consultation.
  • Consider schedule modification for conventional subcutaneous immunotherapy; consider suspending treatment with preseasonal subcutaneous immunotherapy, unless there is unavoidable exposure to a trigger resulting in anaphylaxis.
  • Defer initiation and updosing of food immunotherapy; all patients should be held at their current dose until normal services resume.
  • Venom immunotherapy should not be initiated. Patients on maintenance venom immunotherapy can be spaced to every 2-3 months, if they have been on maintenance for at least a year.

British Society for Allergy and Clinical Immunology and the UK Primary Immunodeficiency Network: COVID-19: Recovery of Allergy and Immunology Services

Last updated 29 June 2020

  • The BSACI and the UKPIN have produced a document on recovery of allergy and immunology services post-COVID-19.
  • Specialist services need to be proactive in identifying ways of prescribing medications for patients reviewed remotely rather than adding to primary care workload; this can be facilitated by lead pharmacists in the organisations, and might be achieved by prescription through the hospital outpatient pharmacy for patients to collect (or the hospital inpatient or outpatient pharmacy to post to patients), or the use of FP10 prescriptions for community pharmacies, although this will need local agreement due to cost implications.
  • Services should be mindful that there will be some medications which GPs are unwilling or unable to prescribe, for example omalizumab for home therapy, immunosuppressive agents, sublingual immunotherapy products, or C1-inhibitor or lanadelumab for hereditary angioedema (HAE) prophylaxis.
  • In such cases, shared care and/or commissioning agreements may need to be reached, or home care provision arranged. Every reasonable attempt should be made to avoid passing the responsibility to primary care, although sometimes this may be impossible to avoid
  • Patients with HAE or acquired C1-inhibitor deficiency acquired angioedema whose disease is poorly controlled despite preventive treatment and rescue medications require review even if the service is restricted, in order to assess eligibility for alternative treatments. There is an unavoidable need to be able to train patients face-to-face in self-administration of treatment for swellings.

British Transplantation Society: COVID-19 Information for Transplant Professionals

  • The British Transplant Society (BTS) and the Centre of Evidence in Transplantation have collaborated to provide an open access repository of current and emerging evidence for solid organ donors, recipients and potential recipients in the context of COVID-19.
  • Has a link to ‘Coronavirus: COVID-19 Information for transplant professionals’, which includes advice such as: patients must be reminded not to stop their immunosuppression in the event of infection, unless recommended to do so by a transplant professional; levels of immunosuppression should be reviewed, but generalised immunosuppression reduction that may jeopardise organ function is not recommended.
  • In conjunction with The Renal Association, has produced ‘Guidance on the management of transplant recipients diagnosed with or suspected of having COVID19’, which discusses when to review, reduce the dose of, or discontinue drugs such as azathioprine, mycophenolate mofetil and calcineurin inhibitors; it also discusses issues with additional agents (such as ACEI, ARB and NSAIDs) and potential interactions between transplant medicines and COVID-19 treatments, such as antivirals used in some trial protocols (note: this guidance does not cover cardiothoracic or small bowel transplant recipients).
  • Have added a Position Statement on Vaccination against COVID-19 in Solid Organ and Islet Transplant Recipients (adults, children and young people) [Last updated 16 April 2021, added 2 February 2021] and Guidance on SARSCoV-2 vaccination in adult solid organ and islet transplant wait-listed patients and adult living donor transplant recipients [Last updated 22 January 2021, added 9 February 2021].

European academy of allergy and clinical immunology: COVID-19 Resource Centre

Last updated 3 March 2021

The European Academy of Allergy and Clinical Immunology (EAACI) has a COVID-19 Resource Centre, with links to relevant documents, including:

  • Handling of allergen immunotherapy in the COVID‐19 pandemic: An Allergic Rhinitis and its Impact on Asthma (ARIA)‐EAACI statement
  • Managing childhood allergies and immunodeficiencies during respiratory virus epidemics – A statement from the EAACI-Section on Pediatrics
  • There is also a Statement on intra-nasal corticosteroids Last updated 5 November 2020:
    • Advises that with current knowledge, intra-nasal corticosteroid sprays can be continued in allergic rhinitis and during the pollen season at recommended doses.
    • Stopping local intra-nasal corticosteroid sprays is not advised as immunosuppression has not been proven; moreover, stopping may lead to increased sneezing, which could lead to spreading of the coronavirus.
    • Moreover; unnecessary SARS-COV 2 testing and doctor´s visits may be avoided by sufficient treatment of allergic airway problems; since patients may confound allergic induced nasal symptoms and cough with signs of virus infection

Kidney Care UK: Coronavirus (COVID-19) guidance for patients with kidney disease

Last updated 26 April 2021

  • Has a section on medications in ‘Coronavirus (COVID-19) guidance for patients with kidney disease’ which discusses blood pressure medications (ACEI/ARBs) and NSAIDs.
  • Unless they are advised otherwise, it is very important that patients continue to take all their immunosuppressive drugs.
  • It also advises of the potential for interactions between COVID-19 treatments such as antibiotics/antifungals and transplant immunosuppression medicines such as tacrolimus, ciclosporin or sirolimus; patients are reminded to that when they start any new medication, to tell the prescriber that they are taking immunosuppressants. However, patients should not change anything unless advised to by their renal team.
  • People who are clinically extremely vulnerable are being offered a free four-month supply of vitamin D supplements, as it may help resist infection with COVID. People with advanced kidney disease are often low in vitamin D, so they may already be prescribed vitamin-D containing supplements, such as Adcal. Additionally, some transplant units are hesitant to prescribe extra vitamin D to people in the first year following a kidney transplant. If patients are unsure if they should take vitamin D supplements or not, they should check with their doctor or team in charge of their care [Added 7 December 2020].

MHRA: Immunomodulatory drugs and pregnancy prevention: temporary advice for management during coronavirus (COVID-19)

Last updated 21 May 2020

  • The MHRA has agreed to temporary modifications to be made to the pregnancy prevention programmes for thalidomide, lenalidomide, and pomalidomide to facilitate home pregnancy testing and remote consultations, where clinically appropriate, during the COVID-19 pandemic.

The UK Primary Immunodeficiency Network: Advice for healthcare professionals looking after patients with Immunodeficiency regarding COVID-19

Last updated 24 March 2020

  • It is recommended that Immunology services should still support the on-going provision of immunoglobulin replacement therapy for patients with immunodeficiency unless they are advised by their trust or national body that this is no longer possible.
  • Day unit attendance may be minimised for patients at high risk of COVID-19 complications in the following ways: starting antibiotic prophylaxis (to replace immunoglobulin therapy); changes to immunoglobulin dosing (by increasing interval); consideration of home therapy.
  • Includes a table on risk stratification of patients with primary immunodeficiencies and secondary antibody deficiencies; the table details how various classes of medications used in these patient groups can affect their risk of COVID-19.
  • Has a document on prioritisation of services if staffing/facilities have reduced capacity, which includes information on managing medicines such as IV immunoglobulin. [Last updated 15 July 2020]
  • Have provided an update on COVID-19, the coronavirus vaccine and the shielding of  patients with primary immunodeficiency.

Resuscitation Council UK: Management of anaphylaxis in the vaccination setting

Last updated December 2020 [Added 23 December]

  • Guidance on management of anaphylaxis in the vaccination setting has been published.
  • This guidance has been extracted from the Resuscitation Council UK (RCUK) Anaphylaxis guideline (2021) and Public Health England (PHE) advice in Immunisation Against Infectious Disease (the Green Book). It has been approved by RCUK, PHE, the British Society for Allergy and Clinical Immunology (BSACI) and the Royal College of General Practitioners.
  • An anaphylaxis pack should be immediately available in each location where vaccines are being given, and should not be stored in a locked cupboard or trolley. Staff should check packs regularly to ensure the contents are within their expiry dates.
  • An anaphylaxis pack normally contains at least: Two ampoules of adrenaline (epinephrine) 1mg/ml (1:1000); four 23G needles and four graduated 1ml syringes; oxygen supply, with face masks suitable for children and adults and tubing.
  • Note that antihistamines and steroids are no longer recommended for the immediate management of anaphylaxis, and do not need to be included in the emergency anaphylaxis pack.

The UK Primary Immunodeficiency Network: Change in advice for children (under 18 years) with Primary Immunodeficiency regarding COVID-19

Last updated 9 November 2020 [Added 24 November 2020]

  • The UKPIN have produced a document ‘Change in advice for children (under 18 years) with Primary Immunodeficiency regarding COVID-19’.
  • The majority of children with primary immunodeficiency are not considered at increased of severe COVID-19 disease and should be treated exactly the same as other children. This includes continuing to go to school.
  • Those patients under 18 years of age that are: on immunoglobulin replacement therapy (excluding extremely vulnerable diagnoses), on prophylactic antibiotics (excluding extremely vulnerable diagnoses) or on immunosuppressive medication including biologics / monoclonal antibodies (excluding extremely vulnerable diagnoses) are not considered at high risk of COVID-19 disease.
  • A small group of children with the most severe forms of primary immunodeficiency remain at high risk of COVID-19 disease (as well as being vulnerable to other common viral infections). These patients remain in the extremely vulnerable group.

Administration update (27th April 2021): Link to ‘Position Statement on Vaccination against COVID-19 in Solid Organ and Islet Transplant Recipients (adults, children and young people)’ updated.