Summary of COVID-19 medicines guidance: Respiratory disorders

Samantha Owen, Principal Pharmacist Critical Evaluation and UKMi Medicines Q&A Lead, Southampton Medicines Advice Service, University Hospital of Southampton NHS Foundation TrustPublished

This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and respiratory 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:

NHS England/NHS Improvement: Guidance for the role and use of non-invasive respiratory support in adult patients with coronavirus (confirmed or suspected)

Last updated 26 Mar 2020

  • Guidance to advise clinicians on the appropriate use of continuous positive airway pressure (CPAP), non-invasive ventilation and high flow nasal oxygen in patients with confirmed or suspected COVID-19.
  • Includes advice to consider drug interactions when instituting low-dose sedation to aid tolerance of CPAP/NIV (e.g. lopinavir-ritonavir with benzodiazepines), and on use of low doses of agents to improve comfort and tolerance.

NHS England/NHS Improvement: Clinical guide for the optimal use of oxygen therapy during the coronavirus pandemic

Last updated 9 April 2020

  • Guidance to assist with managing demand on the flow of oxygen delivery within hospitals by adjustment of oxygen prescribing targets (oxygen saturation).

NHS England/NHS Improvement: Clinical guide for extra corporeal membrane oxygenation (ECMO) for respiratory failure in adults during the coronavirus pandemic

Last updated 25 June 2020

  • Guidance on indications for respiratory ECMO and information and links to forms for referral of patients to the National ECMO service or to seek clinical advice on the management of severe acute respiratory failure.

NHS England/NHS Improvement: Novel coronavirus (COVID-19) standard operating procedure: COVID Oximetry @home [added 25 November 2020]

Published 13 November 2020

  • Further to guidance on the use of pulse oximetry published June 2020, all CCGs are recommended to put in place a “COVID Oximetry @home” model as rapidly as possible during November 2020.
  • This SOP outlines the patient journey from referral to triage to onboarding to monitoring to recovery and discharge, and provides details on supply and safe re-use of pulse oximeters, including how to order and distribute them safely to patients.
  • Oximeters should be available for same day distribution to patients, including out of hours (ideally within 12 hours).

NHS England/NHS Improvement: COVID-19 therapy: corticosteroids including dexamethasone and hydrocortisone [added 25 November 2020]

Published 13 November 2020

  • Advice highlighting WHO guidance for systemic corticosteroids to be used only in patients with severe and critical COVID-19 disease. Provides an update to advice in MHRA CAS Alert (see below).
  • Dexamethasone is indicated for (suspected or confirmed) COVID-19 in hospitalised adult patients having oxygen therapy, non-invasive or invasive ventilation, or ECMO.
  • Evidence of benefit of dexamethasone in children is unproven, and is still being studied (e.g. RECOVERY trial).
  • Pregnant or breastfeeding women should receive oral prednisolone (40mg) or IV hydrocortisone (80mg twice daily) rather than dexamethasone.

NICE: COVID-19 Prescribing briefing: corticosteroids [added 25 November 2020]

Last updated October 2020.

  • A summary of the evidence to support implementation of the MHRA CAS Alert Corticosteroids in the treatment of suspected or confirmed COVID-19 (see below). Provides a visual representation of the results of the RECOVERY study of dexamethasone in hospitalised patients with COVID-19 who were on oxygen but not mechanical ventilation and patients who were on mechanical ventilation at the start of the study.

NICE: COVID-19 rapid guideline: severe asthma

Last updated 3 April 2020

  • This guideline includes recommendations for treatment of severe asthma, including biological treatment and corticosteroids
  • It also includes recommendations for safe use of equipment, including face masks, nebulisers, inhalers, spacers and peak flow meters
  • There is a recommendation not to prescribe more than 30 days’ supply of asthma medicines per patient to protect the supply chain

NICE: COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD)

Last updated 9 April 2020

  • This guideline includes recommendations for treatment of COPD including advice on treatment with inhaled or long-term oral corticosteroids, self-management of exacerbations, smoking cessation, pulmonary rehabilitation, oxygen, prophylactic oral antibiotics and airway clearance techniques
  • It also includes recommendations for safe use of equipment, including face masks, nebulisers, inhalers, spacers and peak flow meters, and for patients receiving home non-invasive ventilation
  • There is a recommendation to carry out or defer assessments on a case-by-case basis to establish eligibility for long-term oxygen therapy or home non-invasive ventilation, and not to prescribe more than 30 days’ supply of COPD medicines per patient to protect the supply chain

NICE: Medtech innovation briefing myCOPD for self-management of chronic obstructive pulmonary disease

Last updated 1 April 2020

  • Review of the myCOPD digital self-management tool (app), a registered class I medical device, for consideration as part of self-management for people as an alternative to some routine healthcare visits such as pulmonary rehabilitation

NICE: COVID-19 rapid guideline: cystic fibrosis

Last updated 7 October 2020

  • Includes advice on safety of nebuliser treatment for patients with known or suspected COVID-19 infection (recommendation 1.14)
  • Provides recommendations on continuing with usual CF self-care treatments of including prophylactic antibiotics (oral and IV), mucoactive agents, CFTR therapies, and diet, vitamins and pancreatic enzyme replacement therapy
  • It also includes recommendations on hygiene of equipment, including face masks and nebulisers, recommendations not to exceed normal quantities of medicines on prescription (usually 30 days) to protect the supply chain, and to follow previous advice on management of exacerbations
  • Advice is given for specialist CF centres to maintain sufficient access to day-case facilities for procedures such as administering first doses of IV antibiotics for courses to be delivered at home and flushing totally implantable intravenous devices. Flushing frequency may be reduced from usual practice or home visit may be considered if no alternative is possible (recommendation 3.4).
  • Recommendations are provided for access and monitoring of patients on CFTR therapies (recommendation 3.9)

NICE: Medtech innovation briefing [MIB219] CFHealthHub for managing cystic fibrosis during the COVID-19 pandemic

Last updated 10 July 2020

  • Review of CFHealthHub, a digital platform to help adults with cystic fibrosis (CF) manage their condition and monitor their medicine use.
  • Use of this technology may allow people to attend virtual clinics, supporting those shielding from COVID-19.

NICE: COVID-19 rapid guideline: interstitial lung disease

Last updated 15 May 2020

  • Includes advice for patients to keep a list of their current medicines, conditions and allergies, as well as a copy of a recent clinic letter, to give to healthcare staff if they need treatment for COVID-19.
  • Includes advice on assessing symptoms, including reminders of possible atypical presentation in patients taking immunosuppressants, and potential for confusion with adverse effects of antifibrotics or immunosuppressants and symptoms of COVID-19, as well as increased risk of coagulopathy in patients with ILD and COVID-19 with link to BTS guidelines for VTE (see below).
  • Also recommends considering alternatives to hospital attendance for blood monitoring in patients taking antifibrotics or immunosuppressants, e.g. community blood monitoring services.
  • Provides guidance on starting and continuing treatments (e.g. immunosuppressants and antifibrotics) for ILD, and on oxygen assessment. Also offers guidance on continuing or stopping treatments for ILD in patients known or suspected to have COVID-19, including in patients who develop acute kidney injury or deranged LFTs due to COVID-19.
  • Provides advice on supply of medicines, including planning for managing any disruption to normal supply routes, and advice not to prescribe in large quantities.

NICE: Medtech innovation briefing [MIB217] Cytokine absorption devices for treating respiratory failure in people with COVID-19

Last updated 21 May 2020

  • Review of cytokine absorption devices for reducing harmful blood levels of cytokines in people who have tested positive for COVID-19 and have imminent or confirmed respiratory failure.
  • This treatment would be given by trained intensive care consultants and specialist nurses on critical care units as a standalone therapy or with other extracorporeal therapies including renal replacement therapy and oxygenation membrane therapy.

NICE:COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19 [added 25 November 2020]

Last updated 20 November 2020

  • This guideline covers pharmacological VTE prophylaxis for patients being treated for COVID-19 pneumonia, including patients receiving treatment in hospital or in a community setting such as a ‘hospital at home’ service or COVID-19 ‘virtual ward’. 
  • Following risk assessment, offer pharmacological VTE prophylaxis, unless contraindicated, with a standard prophylactic dose (for acutely ill medical patients) of low molecular weight heparin (LMWH).
  • For patients at extremes of body weight or with impaired renal function, consider adjusting the dose of LMWH in line with the summary of product characteristics and locally agreed protocols.
  • Start VTE prophylaxis as soon as possible and within 14 hours of admission and continue for the duration of the hospital stay or 7 days, whichever is longer.
  • For patients having advanced respiratory support: consider increasing pharmacological VTE prophylaxis to an intermediate dose (off-label), taking account of body weight and renal function and basing the decision on multidisciplinary or senior opinion, or locally agreed protocols

MHRA: CAS Alert: Corticosteroids in the treatment of suspected or confirmed COVID-19  [added 25 November 2020]

Issued 3 Sept 2020

  • Based on the results of the REMAP-CAP trial for hydrocortisone and a meta-analysis of corticosteroids, the MHRA has advised that corticosteroids have been demonstrated to have a clear place in the management of patients with severe or critical COVID-19 disease (as defined by WHO – definitions provided within CAS) but should not be used in patients with non-severe disease. It is stated the guidance applies primarily to patients who are hospitalised and receiving supplemental oxygen but may apply to some non-hospitalised patients.
  • The following dose regimens for adults are recommended: dexamethasone 6mg (orally or by injection) once daily for 7-10 days or hydrocortisone 50mg (by injection) three times daily for 7 -10 days. Treatment should stop if discharged from hospital within 10 days. A longer low-dose hydrocortisone regimen (lasting up to 28 days) may be considered for use in patients with septic shock.
  • Prescribers are referred to relevant SPC for use in children, pregnancy or breastfeeding women.
  • Co- prescription of a PPI should be considered for gastroprotection according to local policies
  • Interaction advice with remdesivir updated to state: “Coadministration has not been studied but based on metabolism and clearance a clinically significant interaction is unlikely”

Asthma UK: Coronavirus (COVID-19) Health advice for people with asthma

Updated on an ongoing basis

  • Links to guidance for patients on reducing risk of getting coronavirus and managing their asthma well to reduce the risk from coronavirus
  • Shielding advice for very high risk patients and how to identify who should be shielding (e.g. which treatments are included)
  • Guidance for patients with asthma on what to do if they get COVID-19

British Thoracic Society: COVID-19: information for the respiratory community

Last updated 6 November 2020

Provides information, guidance and resources to support the respiratory community during the COVID-19 pandemic, as well as further information on identifying patients for shielding , guidance for the resumption and continuation of outpatient respiratory services, and links to resources for patients with lung disease. Of particular relevance to medicines use is:

Cystic Fibrosis Trust: The impact of coronavirus on your CF care

Last updated 17 July 2020

  • Provides answers to some of the questions raised by people with CF and their families concerned about changes to the way their care is delivered because of the COVID-19 outbreak.
  • Includes a link to for patients to download a CF Medical Information Card to be presented in the event of hospital attendance to inform hospital staff of their treatments or care.

Cystic Fibrosis Trust: Coronavirus and cystic fibrosis updates and FAQs

Last updated 5 November 2020

  • Provides answers to commonly asked questions about COVID-19 and how it affects people with CF and their families
  • Includes advice about access to medicines, as well as advice for people taking part in a clinical trial

Cystic Fibrosis Trust: Government and clinical guidance

Last updated 4 November 2020

  • Provides links to the lastest clinical and government guidance, including links to the latest statements from the UK CF Medical Association, information and statistics on numbers of people with CF who have or have had COVID-19, guidance for clinically extremely vulnerable individuals and information for the general population and and mental health and wellbeing aspects of COVID-19.

Primary Care Respiratory Society: COVID-19 Guidance 

Last updated 9 November 2020

  • Provides links to PCRS COVID-19 guidance as well as advice from other health professions and links to other information resources
  • Of particular relevance to medicines is the PCRS Pragmatic Guidance for crisis management of asthma and COPD during the UK Covid-19 epidemic. This guidance aims to respond to questions from primary care, especially around steroid use. Questions include whether oral corticosteroids (OCS) worsen outcomes, whether rescue packs should be issued, whether nebulisers should still be given if indicated, whether all asthma patients should be started on inhaled corticosteroid (ICS), whether ICS should be stopped or reduced in stable asthma or COPD, and whether to advise patients to increase ICS dose or use OCS in asthma attacks or COPD exacerbation if Covid-19 may be the cause.

Administration update (25th November 2020): new resources added to the page as indicated by red text.