Overview

The purpose of this guideline is to maximise the safety of children and adults who have gastrointestinal or liver conditions treated with drugs affecting the immune response during the COVID-19 pandemic. It also aims to protect staff from infection and enable services to make the best use of NHS resources.

On 9 April 2021, we updated recommendations on treatment considerations for patients not known to have COVID-19 to take into account COVID-19 vaccination status.

This guideline focuses on what you need to stop or start doing during the pandemic. Follow the usual professional guidelines, standards and laws (including those on equalities, safeguarding, communication and mental capacity), as described in making decisions using NICE guidelines.

This guideline is for:

• health and care practitioners
• health and care staff involved in planning and delivering services
• commissioners.

The recommendations bring together:

• existing national and international guidance and policies
• advice from specialists working in the NHS from across the UK. These include people with expertise and experience of treating patients for the specific health conditions covered by the guidance during the current COVID-19 pandemic.

NICE has also produced a COVID-19 rapid guideline for children and young people who are immunocompromised, which should be read alongside this guideline.

We developed this guideline using the interim process and methods for developing rapid guidelines on COVID-19 in response to the rapidly evolving situation. We will review and update the recommendations as the knowledge base develops using the interim process and methods for guidelines developed in response to health and social care emergencies.

1. Communicating with patients and minimising risk

1.1.

Communicate with patients, their families and carers, and support their mental wellbeing to help alleviate any anxiety and fear they may have about COVID-19. Signpost to charities (such as Crohn’s & Colitis UK, the British Liver Trust, the Crohn’s in Childhood Research Association, and the Children’s Liver Disease Foundation), support groups (including NHS Volunteer Responders) and UK government guidance on the mental health and wellbeing aspects of COVID-19.

1.2.

Provide patients, their families and carers with information that meets their communication needs (see NHS England’s Accessible Information Standard).

1.3.

Some patients will have received a letter telling them they are at high risk of severe illness from COVID-19. Tell them, or their parents or carers:

• to refer to the advice on shielding in UK government guidance on shielding and protecting people defined on medical grounds as extremely vulnerable to COVID-19
• that their level of risk may change, as a result of advice from their primary care team, specialists or changes in government guidance.

1.4.

Telephone, email or text patients booked for a gastroenterology or hepatology appointment, or their parents or carers. Tell them:

• not to stop or change their medication without discussing with their gastroenterology or hepatology team first
• that they can continue taking aminosalicylates, and that these drugs do not affect the immune response
• to write down a list of the medicines they take and any conditions they have, to give to healthcare staff if they need to seek treatment for COVID-19
• that if they have been advised to self-isolate they should follow the UK government stay at home advice for households with possible coronavirus infection.

1.5.

Minimise face-to-face contact by:

• using telephone, video or email consultations whenever possible
• cutting non-essential face-to-face appointments
• contacting patients via text message, telephone or email
• using electronic prescriptions rather than paper
• using different methods to deliver prescriptions and medicines, for example, pharmacy deliveries, postal services, NHS Volunteer Responders or introducing drive-through pick-up points for medicines
• extending intervals between drug monitoring (see recommendation 2.8 in the section on treatment considerations) and using local services for blood tests if possible.

1.6.

If patients need to attend face-to-face appointments, ask them to help reduce the risk of contracting or spreading COVID-19 by:

• coming to the appointment alone
• having only 1 parent or carer accompany a child or adult who cannot come alone
• avoiding public transport if possible.

1.7.

Tell patients who still need to attend services to follow relevant parts of government advice on social distancing (this differs across the UK) and UK government advice on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19.

1.8.

Tell patients, and their families and carers, that they should contact the NHS 111 online coronavirus service if they think they have COVID-19. In an emergency they should call 999 if they are seriously ill. They should also contact their gastroenterology or hepatology team to get advice about any drugs they are taking that affect the immune response.

2. Patients not known to have COVID-19

2.1.

Minimise time in the waiting area by:

• careful scheduling
• encouraging patients not to arrive early
• texting patients when you are ready to see them, so that they can wait outside, for example, in their car
• providing a ‘clean route’ through the hospital to the department
• delivering treatment promptly
• ensuring prescriptions are dispensed rapidly.

2.2.

Be aware that worsening gastrointestinal symptoms and deteriorating liver function test results could be associated with COVID-19.

2.3.

Be aware that patients taking drugs that affect the immune response may have atypical presentations of COVID-19. For example, patients taking corticosteroids may not develop a fever.

2.4.

Be aware that patients with decompensated liver disease may be at higher risk of severe COVID-19 when taking drugs affecting the immune response.

3. Patients known or suspected to have COVID-19

3.1.

If patients with symptoms of COVID-19 need to attend the gastroenterology or hepatology department, follow appropriate UK government guidance on infection prevention and control for COVID-19. This includes recommendations on using personal protective equipment (PPE), patient transfers, and options for outpatient settings.

3.2.

If COVID-19 is later diagnosed in a patient not isolated from admission or presentation, follow UK government guidance for health professionals.

4. Modifications to usual care

4.1.

Think about how to modify usual care to reduce patient exposure to COVID-19 and make best use of resources (workforce, facilities, equipment).

4.2.

If it becomes impossible to provide usual services, prioritise core services. These include:

• services for urgent inpatient and outpatient review (both new and follow-up)
• essential face-to-face reviews to manage disease flares and complications of therapy
• advice lines
• essential infusion services
• blood tests for drug monitoring that cannot safely be delayed.

4.3.

For recommendations on delivering planned care, including interventional or diagnostic procedures, see the NICE COVID-19 rapid guideline on arranging planned care in hospitals and diagnostic services. For specific advice on resuming endoscopy services, refer to the British Society of Gastroenterology guidance on restarting gastrointestinal endoscopy in the deceleration and early recovery phases of the COVID-19 pandemic. [amended 21 August 2020]

4.4.

Provide advice and guidance to GPs, to avoid unnecessary emergency department attendances and admissions.

4.5.

Think about pooling resources with other specialities and NHS trusts to provide services such as drug monitoring and telephone and email advice.

5. Healthcare workers

5.1.

All healthcare workers involved in receiving, assessing and caring for patients who have known or suspected COVID-19 should follow UK government guidance on infection prevention and control for COVID-19. This contains information on using personal protective equipment (PPE), including visual and quick guides for putting on and taking off PPE.

5.2.

If a member of staff needs to self-isolate, ensure that they can continue to help by:

• enabling telephone or video consultations and virtual attendance at multidisciplinary team meetings
• identifying patients who are suitable for remote monitoring and follow-up, and those who are vulnerable and need support
• carrying out tasks that can be done remotely, such as entering data.

5.3.

Support staff to keep in touch as much as possible, to support their mental wellbeing.

5.4.

Provide all staff with visible leadership and supportive messaging to maintain morale.

5.5.

Take account of the information on the NHS Employers website about good partnership working and issues to consider when developing local plans to combat COVID-19.

Update information

9 April 2021: In section 2 we added a recommendation to follow advice on COVID-19 vaccination for patients having or going to be having immunosuppressive treatments. We also added a question on COVID-19 vaccination to recommendation 2.6. In recommendation 2.5 we removed the crossreferences to specialist guidance.

21 August 2020: We updated recommendations in section 4 on delivering planned care in line with our guideline on arranging planned care in hospitals and diagnostic services, and linked to British Society of Gastroenterology guidance on restarting gastrointestinal endoscopy.

Your responsibility: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.