Rheumatology services

From consultant Rheumatologists at Broomfield Hospital, 9 April 2021

The Government has outlined its roadmap out of the lockdown, with a gradual easing of restrictions over the next few months that will apply to everyone. In addition, the vaccination programme continues to be rolled out to everyone, with prioritisation based on the advice from the Joint Committee on Vaccination and Immunisation (JCVI). This will help pave the way for restrictions to be safely lifted.

Although the advice to shield has ended, clinically extremely vulnerable people must continue to follow the rules that are in place for everyone.

https://www.gov.uk/guidance/covid-19-coronavirus-restrictions-what-you-can-and-cannot-do

1. If you are clinically extremely vulnerable

If you are clinically extremely vulnerable, you could be at higher risk of severe illness from coronavirus. You are no longer advised to shield, but you should continue to follow the guidance for people who are clinically extremely vulnerable and are advised to take additional precautions to protect yourself.

https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

2. COVID-19 vaccination for patients being on immunosuppressive medication (listed in the risk assessment tool – point 6):

Three vaccines are authorised by Medicines and Healthcare products Regulatory Agency (MHRA) for use in the UK:

• Pfizer/BioNTech
• Oxford/AstraZeneca
• Moderna 

All vaccines are recommended by the Joint Committee of Vaccination and Immunisation (JCVI) for immunosuppressed patients. Patients receiving rituximab treatment should ideally schedule their vaccination date at least a month or more before their infusion. Patients are not required to discontinue their immunosuppressive medications, detailed in the risk assessment tool, around the time of the above vaccinations.

Further advice about vaccination is available through these websites:

https://www.versusarthritis.org/covid-19-updates/vaccines-for-covid-19-your-questions-answered/

https://www.rheumatology.org.uk/practice-quality/covid-19-guidance

3. Covid-19 Vaccination of permanent household members of severely immunosuppressed patients

Eligible household contacts are being advised to call their registered GP practice to book a vaccination appointment and they will then be invited to attend the primary care network-led Local Vaccination Services (LVS) site.

Definition of severely immunosuppressed individuals is the definition of a clinically extremely vulnerable individual in the risk assessment tool below.

Definition of adult household contacts We are using the same principles to define household contacts in this context as those used in the Greenbook Chapter 19: Influenza “individuals who expect to share living accommodation on most days…and therefore, for whom continuing close contact is unavoidable.”

The JCVI advice covers individuals aged 16 years or over only. Those household contacts aged 16-17 years old will need to receive the Pfizer/BioNTech vaccine. Children are excluded.

4. Phlebotomy services during the Covid-19 outbreak

Mid Essex Phlebotomy Services has changed their services for appointment only service in response to Covid-19. Visit /blood-tests for more information and to register and book your appointment.

5. Frequency of blood test monitoring during the Covid outbreak during the Covid-19 outbreak

If you are under shared care we have communicated to your GP about any changes to blood test monitoring. Please contact your GP to enquire about these.

If you are on an immunosuppressive, but not under shared care yet, please continue blood monitoring as your rheumatologist has advised. You can contact our CNS helpline on 01245 514193 should you wish to clarify this further.

Useful information about coronavirus infection for those with rheumatological conditions is available here - https://www.versusarthritis.org/news/2020/april/coronavirus-covid-19-what-is-it-and-where-to-go-for-information

6. Risk assessment tool for people receiving treatment for chronic rheumatic diseases in the context of the COVID-19 infection to determine whether they are clinically vulnerable or clinically extremely vulnerable

If you score 3 or more you are considered as clinically extremely vulnerable

If you score between 1 and 2 you are considered as clinically vulnerable

Risk factors

• Long term (more than 4 weeks) Prednisolone dose 20 mg or above daily score 3
• Long term (more than 4 weeks) Prednisolone dose between 5 and 19 mg daily score 2
• Cyclophosphamide at any dose orally or IV within last six months score 3
• One immunosuppressive medication (conventional* or biologic/monoclonal** or small molecule immunosuppressant***) score 1
• Two or more immunosuppressive medication (conventional* or biologic/monoclonal** or small molecule immunosuppressant*** ) score 2
• Aged more than 70 years regardless of health problems score 1
• Aged less than 70 years AND other health problems**** score 1
• Hydroxychloroquine, Sulfalsalazine alone or in combination score 0

*Conventional immunosuppressive medications include: Azathioprine, Leflunomide, Methotrexate, Mycophenolate (mycophenolate mofetil or mycophenolic acid), ciclosporin, Tacrolimus, Sirolimus. It does NOT include Hydroxychloroquine or Sulphasalazine, either alone or in combination.

**Biologic/monocolonal includes: Rituximab within last 12 months; all anti-TNF drugs (etanercept, adalimumab, infliximab, golimumab, certolizumab and biosimilar variants of all of these); Tociluzimab; Abatacept; Belimumab; Anakinra; Seukinumab; Ixekizumab; Ustekinumab; Sarilumumab; Canakinumab

***Small molecules includes: baracitinib, tofacitinib, apremilast

****Other health problems include: Heart attack (myocardial infarction), chronic heart failure, hypertension, ischaemic heart disease, chronic lung disease, interstitial lung disease, pulmonary arterial hypertension, peripheral vascular disease (blocked arteries in your limbs), stroke (cerebrovascular accident) or TIA (transient ischaemic attack), dementia, connective tissue disease, peptic ulcer disease, chronic liver disease (not short-lived abnormalities of blood test),Diabetes Mellitus, chronic kidney disease (on or being considered for dialysis, post-kidney transplant), cancer, AIDS (not just HIV positive).

The Rheumatology team provides a broad base of expertise in rheumatic disorders in close liaison with our Physiotherapy and Occupational Therapy departments.

Specialist diagnostic and monitoring services are available for patients with all forms of rheumatic disease including the following conditions:

• Inflammatory arthritis (including rheumatoid arthritis for both adults and children) - visit  https://www.nhs.uk/conditions/arthritis to find out more, including:
  • rheumatism
  • ankylosing spondylitis
  • psoriatic arthritis
  • other inflammatory arthritis.
• Osteoarthritis - https://www.nhs.uk/conditions/osteoarthritis
• Osteoporosis - https://www.nhs.uk/conditions/osteoporosis
• Connective tissue diseases
  • SLE (Lupus) -  https://www.nhs.uk/conditions/lupus
  • Sjorgren's syndrome
  • Systemic sclerosis
  • Myositis -  https://www.nhs.uk/conditions/myositis
  • Suspected Polymyalgia rheumatica (PMR) or painful muscles - https://www.nhs.uk/conditions/polymyalgia-rheumatica
  • GCA
  • other vasculitis and auto-immune disorders.
• Infective and metabolic bone disease
  • Osteoporosis -  https://www.nhs.uk/conditions/osteoporosis
  • Male osteoporosis
  • Young osteoporosis
  • eating disorders -  https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/eating-disorders
  • Paget's disease -  https://www.nhs.uk/conditions/pagets-disease-bone
  • Osteogenesis imperfecta
• Regional musculoskeletal problems and Fibromyalgia (diagnosis with ultrasound) - https://www.nhs.uk/conditions/fibromyalgia
• Spinal diseases
• Soft tissue lesions
• Infective bone/joint disease.

We hold outpatients at each of our hospitals:

• Basildon - held at Basildon and Orsett Hospitals.
• Broomfield - held at Broomfield, St Michael’s and St Peters Hospitals.
• Southend – held at Southend Hospital.

In these clinics we treat and carry out diagnostic procedures in clinics, such as:

• inflammatory arthritis and vasculitis
• muscle biopsies and lip biopsies
• joint injections - including image guided injections for joints such as hip and Caudal epidural injection
• Intravenous treatments - biologics, cytotoxic, IV bisphosphonates
• Electromyography (EMG) - on specialist referral
• Nerve conduction velocity (NCV) services - on specialist referral
• early arthritis clinic
• connective tissue diseases clinic
• 'One stop' osteoporosis clinic, including DEXA scan
• combined paediatrics/rheumatology clinic
• musculoskeletal ultrasound
• biologic screening
• DMARD monitoring
• injection clinic.

Large cohort of patients on Biologic Therapies Paediatric and Adolescent patients are seen in paediatric multidisciplinary setting.

We work closely with other hospitals such as the Royal Free, UCL and Great Ormond Street Hospital for management of these patients.

The rheumatology department is involved in many research studies.

If you are eligible and meet the criteria, we may ask offer you the opportunity to take part.

If you are interested, please ask your consultant and they will be able to advise you further.

We only accept referrals from GPs and other healthcare practitioners.

If you need to refer to us, email mse.rheumatology@nhs.net.  

We do not have the facility to support walk-in requests in the department.

If you need urgent assistance, contact your GP or call NHS 111.