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

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.

This page has been put together rapidly in relation to the COVID-19 pandemic.

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:

NHS England/NHS Improvement: Management of rheumatology patients

Last updated 8 April 2020

  • Provides list of risk factors that would put an individual at very high risk/ extremely vulnerable over and above taking an immunosuppressant medicine (which already puts them at high risk). Additional risk factors include high doses, use of multiple immunosuppressants, active disease and some co-morbidities.
  • Suggested shielding criteria include any patient taking 20mg or more of corticosteroid, any dose of cyclophosphamide, taking 5mg or more corticosteroid plus one or more other immunosuppressants, taking any two immunosuppressants.
  • Patients with very active disease for example when newly diagnosed or receiving IV cyclophosphamide may be at very high risk.
  • Patients must not suddenly stop prednisolone. Guidance is provided on the impact of prednisolone dose on level of risk.
  • Patients infected with Covid-19 should temporarily stop their conventional DMARD and biological therapy and consult their specialist about when to restart treatment.
  • Patients can continue to take hydroxychloroquine and sulfasalazine if infected with coronavirus.
  • A series of mitigating actions are suggested to help counteract the effects of decreased hospital capacity.
  • Consider implications of introducing virtual clinics and 7-day services on medicines management.

NHS England/NHS Improvement: Management of patients with musculoskeletal and rheumatic conditions on corticosteroids

Last updated 16 June 2020

  • Patients on long-term steroids should not stop their treatment suddenly.
  • Think before starting corticosteroids in the current pandemic. If there is no alternative use the lowest dose and taper corticosteroid as fast as possible in the clinical context. Suggested maximum doses of oral prednisolone are provided for various clinical indications and it is recommended that higher doses should only be used on specialist advice. It is noted that starting a patient on 20mg prednisolone (or 0.5mg/kg/day for children) for more than one month will move them into the shielding group and more than 5mg per day could move them into the shielding group.
  • Standard advice not to administer steroid injections to patients with active infections is emphasised
  • A one off-dose of corticosteroid injection for local action or a one-off intramuscular corticosteroid injection will not move patients into the shielding group
  • Intramuscular corticosteroids should only be used to control significant disease flare that is compromising a patient’s ability to function and consideration should be given to using low doses (eg a maximum of 120mg methylprednisolone).
  • Only consider intra-articular, peri-articular and soft tissue corticosteroid injections if patient has high levels of pain/disability, has failed first-line therapies and continuation of symptoms will have a significant impact on health and well-being.
  • Generally avoid corticosteroid injections for spinal conditions. Recommend simple analgesia, activity modification and exercise and consider referral for epidural or nerve root block for severe radicular pain.
  • Intravenous methylprednisolone should be reserved for patients with clinically active disease and only used on the advice of a specialist.
  • Guidance is provided to assess the appropriateness of use of corticosteroids on a case-by-case basis. Any local PGDs should be reviewed to ensure they align with this advice.

NICE COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders

Updated 2 July 2020

  • Supports guidance recommendations from BSR (outlined below) but additionally highlights factors that should be taken into consideration when stopping immunosppressive medicines in children and adolescents and points out that immunosuppressive effects will persist for some time after stopping the medicine
  • 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.
  • 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 29 July 2020

  • BSR advise that some patients that received shielding letters may not actually be higher-risk and some that have not received letters should be treated as higher-risk– clinicians may review and advise on an individual patient level.
  • 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 corticosterods who are considered at risk of adrenal suppression and become co-infected with Covid-19. It is consdered that the standard advice to double the dose of corticosteroid in patients with intercurrent infection may not be sufficient.
  • 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.

NHS England/NHS Improvement: Management of trauma and orthopaedic patients

Updated 14 April 2020

  • An anaesthetic guideline for patients requiring surgery and who are coronavirus positive will be required.
  • Make contingency plans for supply chain issues

NHS England/NHS Improvement: Urgent and emergency musculoskeletal conditions requiring onward referral

Issued 23 March 2020

  • Provides guide to the signs/symptoms and risk factors for emergency and urgent conditions which require onward referral.

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.

Administration update (10th September 2020): resources updated on the page as indicate by red text