NICE releases rapid guidance for primary care clinicians during COVID-19 pandemic

New guidance on the care of patients with suspected and confirmed COVID-19, and guidance for the management of severe asthma and other conditions during the coronavirus pandemic, has been issued by NICE.

Patients with severe asthma must continue using inhaled corticosteroids as prescribed. There is no evidence inhaled corticosteroids increase the risk of getting COVID-19. | GETTY IMAGES
Patients with severe asthma must continue using inhaled corticosteroids as prescribed. There is no evidence inhaled corticosteroids increase the risk of getting COVID-19. | GETTY IMAGES

The new advice, part of a series of rapid guidelines developed by NICE in response to the coronavirus pandemic, covers the management of patients with severe asthma, suspected or confirmed pneumonia, rheumatological disorders, and the management of COVID-19 symptoms in the community.

The guidelines advise clinicians how to modify patient care to reduce exposure to COVID-19 and balance the risks and benefits of treatment during the pandemic. The recommendations are based on evidence and expert opinion and will be reviewed and updated as knowledge on the virus develops.

Symptom management

The guideline on managing COVID-19 symptoms (including at the end of life) in the community provides healthcare professionals with general advice on the management of COVID-19 symptoms such as cough, fever, breathlessness and anxiety.

The guidance recommends the use of simple non-drug measures, such as honey, to manage a mild cough. However, if the cough is distressing, codeine linctus, codeine phosphate tablets or morphine sulfate oral solution could be considered for short-term use.

NICE says that patients are likely to experience fever 5 days after exposure to the infection. Those with fever should be advised to use paracetamol as opposed to an NSAID. 

Patients experiencing breathlessness should be advised to keep the room cool and open windows to improve air circulation. NICE also sets out a series of controlled breathing techniques that could help patients manage their symptoms.

NICE advises clinicians to consider an opioid and benzodiazepine combination for patients with COVID-19 at the end of life, who have moderate to severe breathlessness and are distressed.

Clinicians are also advised to take into consideration potential waste, medicine shortages and lack of administration equipment when prescribing and supplying anticipatory medicines at the end of life. However, the guidance says that if fewer health and care staff are available, subcutaneous, rectal or long-acting formulations may need to be prescribed for carers or family members to administer.

Severe asthma

The rapid guideline for severe asthma reminds clinicians that 'severe asthma is defined by the European Respiratory Society and American Thoracic Society as asthma that requires treatment with high-dose inhaled corticosteroids plus a second controller, and/or systemic corticosteroids to prevent it from becoming or remaining 'uncontrolled' despite this therapy'.

The guideline says all patients, including those with suspected or confirmed COVID-19, should continue taking their regular medication in line with their asthma action plan. Clinicians must ensure action plans are up to date.

Patients who attend hospital to have biological treatments should be trained to self-administer at home if possible, or treatment at a community clinic should be considered. Clinicians must weigh up the risks and benefits of starting any new biological treatment.

To support the supply chain for medicines, patients should be prescribed asthma medication to meet their clinical needs for no more than 30 days.

Because of their potential to spread the virus, pulmonary function tests should only be carried out for urgent cases where the results will have a direct impact on patient care.

Patients should be advised to clean equipment including face masks, mouth pieces, spacers and peak flow meters regularly using a detergent, and not to share their inhalers or devices with anyone else.

Pneumonia and antibiotic prescribing

The rapid guideline on managing suspected or confirmed pneumonia in adults in the community says that as COVID-19 becomes more prevalent, pneumonia is more likely to be caused by the virus than bacteria. Since viral pneumonia will not respond to antibiotics, GPs are advised to prescribe these drugs only if the likely cause is bacterial, if it is unclear whether the cause is bacterial or viral and symptoms are more concerning, or if the patient is at high risk of complications. 

The guideline includes information on how to differentiate between viral pneumonia and bacterial pneumonia:

COVID-19 viral pneumoniaBacterial pneumonia
History of typical COVID-19 symptoms for about a weekNo history of typical COVID-19 symptoms
Severe muscle pain (myalgia)Patient becomes rapidly unwell after only a few days of symptoms
Breathless but no pleuritic painPleuritic pain
Loss of sense of smell (anosmia)Purulent sputum
History of exposure to known or suspected COVID-19

NICE recommends that GPs use the Medical Research Council's dyspnoea scale or the Centre for Evidence Based Medicine's review of ways of assessing dyspnoea by telephone or video in order to assess breathlessness remotely. Use of the ROTH tool is not advocated.

The CRB65 tool recommended in NICE's standard guideline on pneumonia diagnosis and management has not been validated in people with COVID-19 since it requires BP measurement, which may not be possible if clinicians are consulting remotely and also risks cross contamination.

Where pulse oximetry is available oxygen saturation levels below 92% (or below 88% in people with COPD) indicate seriously ill patients.

The guideline says the NEWS2 tool for predicting risk of clinical deterioration may be useful. However, face-to-face appointments should not be arranged solely for this purpose.

Admission to hospital 

NICE says that clinicians are advised to take into account the severity of infection and the benefits, risks and disadvantages of hospital admission. Patients must be made aware of the benefits of admission, such as improved diagnostic tests and respiratory support, as well as the risks including spreading or catching COVID-19 and loss of contact with their family. 

Rheumatological disorders

The rapid guideline on rheumatological autoimmune, inflammatory and metabolic bone disorders advises clinicians to be aware that patients on immunosuppressants may have atypical presentations of COVID-19 eg, those taking prednisolone may not develop a fever, and those taking interleukin-6 inhibitors may not develop a rise in C-reactive protein.

When deciding on treatments, NHS England's clinical guide on the management of rheumatology patients should be used. This includes a list of patients who are at risk of infection because of the medicines they are taking and information about risk grading.

Patients with known or suspected COVID-19 should not suddenly stop taking their medication but should seek advice on which medicines to continue and which to temporarily stop.

NICE says that clinicians should assess 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. 

If patients feel unwell, they should contact their rheumatology team about any medication-related issues, or if their condition worsens contact NHS 111 for advice on COVID-19.

All guidelines remind clinicians to signpost patients to charities such as the British Thoracic Society and ARMA (the Arthritis and Musculoskeletal Alliance), to help alleviate any anxiety they may have about COVID-19.

Shielding

Patients must follow government advice on social distancing and shielding if they fall into a high-risk group. They must only attend essential appointments and should be screened via telephone to assess whether they have developed symptoms of COVID-19 ahead of the appointment. Clinicians must follow guidance on infection prevention and control when seeing patients.

Further guidelines will be released and are likely to include COPD, cystic fibrosis and dermatological conditions in people receiving immunotherapy. 

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