Summary of COVID-19 medicines guidance: Musculo-skeletal disorders

Diane Bramley, Highly Specialist Pharmacist Medicines Information, Guy's and St Thomas' NHS Foundation TrustPublished Last updated See all updates

This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and musculo-skeletal disorders.

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: rheumatological autoimmune, inflammatory and metabolic bone disorders

Updated 31st March 2021

  • Supports guidance recommendations from BSR (outlined below) but additionally highlights factors that should be taken into consideration when stopping immunosuppressive medicines in children and adolescents and points out that immunosuppressive effects will persist for some time after stopping the medicine
  • Immunosuppressant medicines and techniques are categorised in terms of risk to patient (low to very high)
  • Assess whether patients having intravenous treatment can be switched to the same treatment in subcutaneous form. If this is not possible, discuss with the patient an alternative subcutaneous treatment.
  • Assess whether maintenance treatment with rituximab can be reduced to 1 pulse or the duration between treatments increased. Assess whether maintenance treatment with rituximab can be stopped or switched to another immunosuppressant
  • Do not postpone treatment with denosumab but treatment with zoledronate can be postponed for up to 6 months.
  • Ensure that patients having intravenous prostaglandins (for example, iloprost, epoprostenol) have had the maximum dose of sildenafil. Assess whether they can be switched to bosentan.
  • Assess with each patient whether it is safe to increase the time interval between blood tests for drug monitoring, particularly if 3‑monthly blood tests have been stable for more than 2 years.
  • Patients starting a new disease-modifying antirheumatic drug should follow recommended blood monitoring guidelines. When this is not possible, they should contact the relevant specialist for advice.
  • Warns that patients infected with Covid-19 on long-term corticosteroids may be at risk adrenal crisis and may need higher doses of corticosteroid than usual (see BSR advice below)

British Society for Rheumatology: COVID-19: guidance for rheumatologists

Last updated 22 September 2021

  • All patients should continue to take their medication unless advised otherwise by their doctor.
  • Patients on long-term corticosteroids should not stop these abruptly but these patients should be reviewed to ensure treatment is necessary and the lowest possible dose is being used. Provides clinical and corticosteroid dosing advice for Covid-19 infected patients on long-term corticosteroids at risk of adrenal infection.
  • If patients develop symptoms of any infection immunosuppressive therapy should be paused for the duration of the infection and until they feel well.
  • Consideration should be given to deferring starting biologics or DMARDs for a few months especially in patients aged over 70 or with co-morbidities. If treatment initiation or escalation is needed treatment options are suggested.
  • Specific dosage adjustment advice is provided to help manage patients on long-term corticosteroids who are considered at risk of adrenal suppression and become co-infected with Covid-19. It is considered that the standard advice to double the dose of corticosteroid in patients with intercurrent infection may not be sufficient. The new NHS Emergency steroid card should be issued to patients considered to be at risk.
  • Corticosteroid injections should only be used in patients with severe disease if there are no alternatives and should not be given to patients with active infection.
  • It is usually safe to reduce blood testing frequency in patients taking DMARDs to three-monthly or even less in stable patients. Cases should be reviewed on an individual basis and the risks of continuing without blood testing weighed against the benefit of staying on DMARDS.
  • Supports NHS advice that you should consider taking a daily supplement of 10 microgram of Vitamin D if you are not going outside often.
  • BSR has published a guide to restarting services based on levels of constraint on staffing and access to supporting services.
  • Links out to a new NHS website
  • Highlights a new NHS website called Your Covid Recovery providing health advice, guidance and links to support for people who have ongoing symptoms and health needs after having COVID-19. There are specific sections about fatigue and musculoskeletal, shoulder and back pain.

NICE. COVID-19 rapid evidence summary: Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19

Evidence summary [ES25]

Published date: 21 May 2020

No evidence was found to suggest that people taking NSAIDs for a long-term condition should be advised to stop treatment in the context of COVID‑19. Stopping or switching NSAID treatment could have a negative impact on some people.




Change history

  1. British Society for Rheumatology reference updated. Resources checked and no updates needed.
  1. Resources checked and no updates needed.
  1. Updated link for reporting a concern. Updated guidance from British Society for Rheumatology.
  1. Updated to include significant new recommendations from NICE
  1. Published