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 TrustLast 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 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 Getting it Right First Time (GIRFT) Reports: Clinical practice guide for improving the management of adult COVID-19 patients in secondary care

December 2020

Respiratory section is detailed on p30-34. Guidance of relevance to respiratory medicines includes:

  • A significant proportion of patients attending hospital with COVID-19 will require oxygen therapy and/or ventilatory support.
  • Local guidelines should be in place for: managing patients with COVID-19 requiring oxygen therapy (taking note of oxygen flows to wards and potential oxygen demand); respiratory support units for the initiation and maintenance/management of ventilatory support either outside or within critical care, use of dexamethasone and remdesivir, documentation of ceilings
    of care / escalation protocols and the follow up of patients post COVID-19

NHS England/NHS Improvement: Novel coronavirus (COVID-19) standard operating procedure: COVID Oximetry @home 

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

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 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.

DHSC: COVID-19 Therapeutic Alert: Interleukin-6 inhibitors (tocilizumab or sarilumab) for critically ill patients with COVID-19 pneumonia (adults)

Issued 1 February 2021

  • UK Interim Clinical Commissioning Policies have now been published, recommending that two Interleukin-6 (IL-6) inhibitors – tocilizumab and sarilumab – are made available as a treatment option for critically ill adult patients (aged ≥18 years) hospitalised with COVID-19 in accordance with the agreed criteria.
  • Organisations are recommended to consider prescribing (off-label) either tocilizumab or sarilumab to hospitalised patients with COVID-19 pneumonia being treated with non-invasive ventilation (including high-flow nasal oxygen therapy or continuous positive airway pressure ventilation) or invasive mechanical ventilation.
  • The criteria described in the published Interim Clinical Commissioning Policies should be used to identify patients with COVID-19 related pneumonia who may be suitable for treatment with tocilizumab or sarilumab.
  • Details for Trusts of how to register interest and obtain supplies are provided in the alert document.
  • Recommended doses are: Tocilizumab 8mg/kg as an intravenous infusion, as a single dose to a maximum dose of 800mg; Sarilumab 400mg (using 2 x 200mg pre-filled syringes) as an intravenous infusion as a single dose.
  • No interactions are expected between tocilizumab or sarilumab and dexamethasone or hydrocortisone, or remdesivir.
  • Monitoring of longer-term progress of patients receiving an IL-6 inhibitor is recommended via recruitment to the ISARIC-CCP study.

DHSC: Supply Disruption Alert: Methylprednisolone powder for solution for injection (all strengths) 

Issued 4 January 2021

  • There is insufficient stock of methylprednisolone injection in the UK to support usual use, e.g oncology and multiple sclerosis, as well as use in the emerging treatment of Acute Respiratory Distress Syndrome (ARDS) in COVID-19.
  • Any organisations using methylprednisolone in the management of ARDS in COVID-19 patients should switch to an alternative agent (options outlined in the document).

MHRA: CAS Alert: Corticosteroids in the treatment of suspected or confirmed COVID-19 

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 information about the COVID-19 vaccine
  • Shielding advice for very high risk groups including advice on how patients can get help to collect medicines
  • Guidance for patients with asthma on what to do if they get COVID-19 including advice not to stop using their asthma medicines

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

Last updated 23 March 2021

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 people with lung disease. Of particular relevance to medicines use is:

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

Last updated 17 December 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 January 2021

  • 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

  • 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 1 February 2021

  • 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.

 

Change history

  1. administration update adding new summaries and updating current summaries and hyperlinks
  2. Published