COVID-19: The Latest NICE Guidance

Peter Russell and Dawn O'Shea

November 24, 2020

Editor's note, 23 March 2021: NICE has replaced its previous rapid COVID-19 guidelines with a new single guideline.

The National Institute for Health and Care Excellence (NICE) has added to its growing set of rapid COVID-19 guidelines.

The latest addition covers reducing the risk of VTE

Reducing the Risk of VTE: NICE Guideline NG186

NICE has published a new COVID-19 rapid guideline on reducing the risk of venous thromboembolism (VTE) in patients with COVID-19. This guideline covers pharmacological VTE prophylaxis for patients being treated for COVID-19 pneumonia. It includes patients receiving treatment in hospital or in a community setting such as a hospital, at home service or COVID-19 virtual ward. It applies to all patients with COVID-19 pneumonia aged over 16 years, including those who have other conditions.

Patients with COVID-19 pneumonia managed in hospital

  1. Assess the risk of bleeding as soon as possible after admission or by the time of the first consultant review.

  2. Use a risk assessment tool published by a national UK body, professional network or peer-reviewed journal, such as the Department of Health VTE risk assessment tool.

  3. Offer pharmacological VTE prophylaxis, unless contraindicated, with a standard prophylactic dose (for acutely ill medical patients) of low-molecular-weight heparin (LMWH).

  4. 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.

  5. For patients who cannot have LMWH, use fondaparinux sodium or unfractionated heparin (UFH). LMWH, fondaparinux sodium and UFH are currently off label for patients under 18 years.

  6. Start VTE prophylaxis as soon as possible and within 14 hours of admission. Continue for the duration of the hospital stay or seven days, whichever is longer.

  7. For hospital patients already having anticoagulation treatment for another condition:

    • Continue their current therapeutic dose of anticoagulation unless contraindicated by a change in clinical circumstances.

    • Consider switching to LMWH if their current anticoagulation is not LMWH and their clinical condition is deteriorating.

  8. If a patient's clinical condition changes, assess the risk of VTE, reassess bleeding risk and review VTE prophylaxis.

  9. For patients who are having advanced respiratory support:

    • Consider increasing pharmacological VTE prophylaxis to an intermediate dose.

    • Reassess VTE and bleeding risks daily.

  10. Organisations should collect and regularly review information on bleeding and other adverse events in patients with COVID-19 pneumonia given intermediate doses of pharmacological VTE prophylaxis.

  11. Ensure that patients who will be completing pharmacological VTE prophylaxis after discharge are able to use it correctly or have arrangements made for someone to help them.

Patients with COVID-19 pneumonia managed in community settings

  1. Assess the risks of VTE and bleeding.

  2. Consider pharmacological prophylaxis if the risk of VTE outweighs the risk of bleeding.

Patients with COVID-19 and additional risk factors

  1. For women with COVID-19 who are pregnant or have given birth within the past six weeks, follow the advice on VTE prevention in the Royal College of Obstetricians and Gynaecologists guidance on coronavirus (COVID-19) in pregnancy.

Information and support

  1. Give patients, and their families or carers if appropriate, information about the benefits and risks of VTE prophylaxis.

  2. Follow the recommendations on giving information and planning for discharge in the NICE guideline on venous thromboembolism in over 16s, including information on alternatives to heparin for patients who have concerns about using animal products.

Offer patients the opportunity to take part in ongoing clinical trials on COVID-19.

This section originally appeared on Univadis, part of the Medscape Professional Network.

Arranging Planned Care in Hospitals and Diagnostic Services: NICE Guideline NG179

The guideline emphasises the need to discuss with people how factors such as being older, their sex, comorbidities, and whether they are from a Black, Asian or other Minority Ethnic group, could influence their treatment decisions in light of their risk of contracting COVID-19.

It says people having planned care involving any form of anaesthesia or sedation should follow comprehensive social-distancing and hand-hygiene measures for 14 days before admission.

They should also be tested for SARS-CoV-2 within 3 days before admission and self-isolate from the day of the test until the day of admission.

People in 'at risk' groups should be advised that some types of surgery, including cardiac procedures, carry additional risks for people with COVID-19, and these patients should consider self-isolating for 14 days before a planned procedure.

People having inpatient surgery with a hospital stay of more than 5 days should be tested for SARS-Cov-2 between 5 and 7 days after admission.

The guideline was produced in collaboration with NHS England and Improvement and a cross-specialty clinical group, supported by the specialist societies and Royal Colleges.

Renal Transplantation: NICE Guideline NG178

The guidance recommends that patients scheduled for a living donor transplant, and their donor, must self-isolate for 14 days before the transplant, along with members of their household, to help make sure neither recipient nor donor has COVID-19.

If a patient requires dialysis in the meantime, this must be done in a COVID-19-secure environment.

If a patient has COVID-19, they should be temporarily removed from the waiting list until they have recovered. Clinicians should notify NHS Blood and Transplant and the Renal Registry about anyone who has had a transplant or is on the waiting list who contracts COVID-19.

Interstitial Lung Disease: NICE Guideline NG177

Clinicians are advised how to adjust care to reduce patients' exposure to COVID-19 and how to balance the risks and benefits of taking drugs that affect the immune response during the pandemic.

It recommends that, for people newly referred to specialist services, wherever possible existing pulmonary function tests, blood tests, and CT scan results should be used to guide diagnosis and treatment. Patients should be referred for relevant tests if these results are not available but are needed to guide urgent care.

Because bronchoscopy and pulmonary function tests have the potential to spread COVID-19, they should only be carried out if the patient urgently needs them and if the results will have a direct impact on their care.

When considering whether to start or continue treatment with an immunosuppressant, the guideline recommends that risks and benefits should be discussed with the patient and should involve all relevant members of the hospital specialist team.

Patients already taking antifibrotic drugs should be advised to continue their treatment because there is no evidence they increase the risk of getting COVID-19.

Chronic Kidney Disease: NICE Guideline NG176

Patients, including those who have symptoms of COVID-19, should continue to take their medicines, including ACE inhibitors, angiotensin receptor blockers, immunosuppressants, and diuretics, as normal unless advised to stop by their healthcare professional.

Patients who are able to should be encouraged to self-monitor and self-manage their condition, including blood pressure monitoring. They should be given access to their medical records to help them.

The guideline also advises that patients should continue to be referred for outpatient appointments if the clinical need is urgent, such as for accelerated progression of CKD, or symptoms of urinary tract obstruction.

Acute Kidney Injury in Hospital: NICE Guideline NG175

The guideline was developed to improve outcomes and reduce the need for renal replacement therapy.

It highlights that acute kidney injury may be common in patients with COVID-19 and can lead to worse outcomes for patients. 

It stresses the importance of maintaining the optimal level of body fluids to prevent and manage the condition, despite difficulties in achieving this.

The guidance acknowledges emerging evidence that suggests the coronavirus might directly harm the kidneys. This makes it particularly important that patients are assessed for AKI on admission to hospital or transfer, monitored for AKI throughout their stay, and that AKI is managed appropriately if it develops.

Children and Young People Who Are Immunocompromised: NICE Guideline NG174

The guideline has been developed for children and young people aged 17 and under who may or may not have COVID-19.

It recommends that healthcare professionals discuss the risks and benefits of continuing or stopping treatment, and reassure patients and carers that immunosuppression does not appear to increase the risk of severe COVID-19.

For children and young people with complex care needs, parents and carers should have a plan in place should they themselves become ill so that the patient can continue to receive care safely.

Children and young people who are immunocompromised include those with:

  • Primary immunodeficiencies

  • Secondary or acquired immunodeficiencies because of their condition

  • Secondary or acquired immunodeficiencies because of immunosuppressive treatment

  • Chronic disease associated with immune dysfunction, such as organ dysfunction or failure or severe inflammatory disease

Antibiotics for Pneumonia in Adults in Hospital: NICE Guideline NG173

Careful antibiotic prescribing and prompt review after testing is emphasised in the guidance.

Most cases of pneumonia during the COVID-19 have been viral, rendering antibiotics ineffective except in cases where there is a bacterial co-infection.

Inappropriate use of antibiotics risks disrupting supplies as well as leading to Clostridioides difficile infection and antimicrobial resistance, it warns.

Patients with suspected or confirmed bacterial pneumonia should be given a broad-spectrum antibiotic as soon as possible unless there is significant confidence about the absence of bacterial co-infection. 

If a patient has suspected sepsis, antibiotics must be started within 1 hour of admission. 
Tests such as blood and sputum samples should be used to inform the review of antibiotics after 24 hours, or as soon as results are available.

Further tests to inform the diagnosis should be carried out, including upper and lower respiratory tract specimens and chest imaging, if appropriate.

Gastrointestinal and Liver Conditions Treated With Drugs Affecting the Immune Response: NICE Guideline NG172

The guideline provides advice for clinicians on how to balance the risks and benefits of taking drugs that affect the immune response during the pandemic.

It recommends that patients diagnosed with COVID-19 should continue to take existing courses of drugs that affect the immune response to minimise the risk of a flare-up.

In cases where patients have COVID-19 symptoms, clinicians should offer advice about any drugs the patients are taking.

Discussions with patients should include the risks and benefits of stopping treatment, severity of the COVID-19, their age, severity of their condition, and other comorbidities.

Acute Myocardial Injury: NICE Guideline NG171

Guidance is aimed at non-cardiology specialists to help them identify, monitor, and treat heart problems in adults with known or suspected COVID-19 but who do not have known pre-existing heart disease.

It highlights that acute myocardial injury was observed in 9.5% of all hospitalised patients dying in Italy with COVID-19, and warned that some of the symptoms were similar to the respiratory complications of COVID-19.

It recommended that all patients with a suspected or confirmed myocardial injury should have their blood pressure, heart rate, and fluid balance monitored. Also, continuous ECG monitoring was advised.

Clinicians are to be aware that treatments that may be used in COVID-19 clinical trials, such as azithromycin and hydroxychloroquine, may lead to arrhythmia. 

As of the 23rd April 2020, azithromycin and hydroxychloroquine can only be used to treat COVID-19 as part of nationally approved randomised controlled trials, the guideline said.

Cystic Fibrosis: NICE Guideline NG170

The guideline said that patients with cystic fibrosis should be helped to continue with their usual self-care arrangements. 
It also explained that patients could still access cystic fibrosis transmembrane conductance regulator (CFTR) therapies under the NHS England policy statement for these drugs.

The guideline highlighted Government guidance on shielding and protecting patients with cystic fibrosis, who are extremely vulnerable to COVID-19.

NICE said it had identified its appraisal of elexacaftor, tezacaftor/ivacaftor (Vertex Pharmaceuticals) fixed dose combination therapy for treating cystic fibrosis with the F508del mutation as being "a therapeutically critical topic within the context of COVID-19". Work on developing guidance was a priority, it said.

Community-based Care of Patients With COPD: NICE Guideline NG168

Patients should be advised to continue taking their regular inhaled and oral medicines, including corticosteroids, in line with their individual self-management plan.

This includes those with COVID-19, or suspected of having it. 

The guidance also recommended that patients with COPD who are still smoking should be strongly encouraged to quit in order to reduce the risk of poor outcomes from COVID-19.

Dermatological Conditions Treated With Drugs Affecting the Immune Response: NICE Guideline NG169

Patients known or suspected to have COVID-19 should continue topical treatments, the guidance said.

Also, the use of topical treatments rather than systemic treatments that affect the immune system should be considered for any new skin conditions.

Decisions on starting or continuing treatment with a drug that affects the immune system should be based on need, it said.

Managing Symptoms in the Community: NICE Guideline NG163

The guideline provided advice to health professionals on the management of cough, fever, breathlessness, and anxiety, delirium, and agitation in those with COVID-19.  

Clinicians should be aware that severe breathlessness can cause anxiety and that this can make breathlessness worse.

Patients should be advised to first treat a mild cough with simple measures and should also avoid lying on their back as this can make it harder to clear the lungs by coughing.
In cases of severe cough, codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution could be considered for short-term use.

Paracetamol should be considered in cases of fever.

Severe Asthma: NICE Guideline NG166

The guideline for people with severe asthma said that patients should continue to take their treatment as prescribed and only attend essential appointments.

They should also attend appointments alone wherever possible.

People with severe asthma should be advised to regularly clean equipment such as face masks and mouth pieces, and avoid sharing inhalers and devices with others.

Pneumonia in Adults: NICE Guideline NG165

Clinicians should be aware that with the increasing prevalence of COVID-19, pneumonia is more likely to be caused by the virus than by bacteria.

Patients should not be prescribed an antibiotic for treatment or prevention of pneumonia in cases where COVID-19 is likely to be the cause and where symptoms are mild.
People should seek medical help without delay if their symptoms do not improve or if their symptoms worsen rapidly, whether they have been given an antibiotic or not.

When possible, clinicians should discuss with patients and carers the risks, benefits, and possible likely outcomes of treatment options.

Rheumatological Autoimmune, Inflammatory, and Metabolic Bone Disorders: NICE Guideline NG167

Patients with COVID-19 should not suddenly stop taking their medication but should seek advice on which medicines to continue and which to temporarily stop, the updated guidance said.

In cases where their condition worsens, patients should contact their rheumatology team about any rheumatological medication issues or contact NHS 111 for advice on COVID-19. 

Healthcare professionals should use NHS England’s COVID-19 clinical guide when deciding what treatments are appropriate.

Delivery of Radiotherapy: NICE Guideline NG162

The guideline advised that treatment should be avoided where evidence suggests little to no benefit.

In cases where an alternative treatment is available, radiotherapy should be deferred, if clinically appropriate.

If radiotherapy treatment is unavoidable, the shortest safe form of treatment should be used.
Changing treatment schedules or interrupting treatment should be discussed with patients, their families, and carers.

Haematopoietic Stem Cell Transplantation: NICE Guideline NG164

Clinicians were advised to consider both the severity of the disease and the post-transplant risks of COVID-19 when deciding on treatment plans.

Autologous transplants and allogeneic transplants should be deferred in most cases until the risks associated with the COVID-19 pandemic have passed.

Treatment decisions should be made on an individual basis by a multidisciplinary team, and the reasons recorded.

Treatment decisions should be communicated to patients, their families, and carers, with support given to their mental wellbeing.

Critical Care: NICE Guideline NG159 

All patients admitted to hospital should be assessed for frailty irrespective of COVID-19 status.

Risks and benefits and likely outcomes should be discussed with patients, carers or advocates, and families using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible.

For patients with confirmed COVID-19, decisions about critical care admission should be made on the basis of medical benefit and should take into account the likelihood that the person will recover to an outcome that is acceptable to them and within a period of time consistent with the diagnosis.

NICE later updated this guidance following concerns from patient groups that assessments for frailty using the Clinical Frailty Scale (CFS) score could put people with learning disabilities, autism, and other stable long-term disabilities at a disadvantage when decisions were made about admission to critical care during a time of intense pressure on the NHS.

Systemic Cancer Treatments: NICE Guideline NG161 

Where decisions need to be made about prioritising patients for treatment, these need to take into account the level of immunosuppression associated with individual treatments and cancer types, and any other patient-specific risk factors. They should also balance the risk from cancer not being treated optimally versus the risk of becoming seriously ill if they contract COVID-19 because of immunosuppression.

Where changes need to be made to usual care because of system pressures, consideration should be given to delivering treatment in different and less immunosuppressive regimens, different locations, or via another route of administration.

Dialysis: NICE Guideline NG160 

Patients with suspected COVID-19 should be assessed to see whether dialysis could be delayed until their COVID-19 status is known.

NICE also recommends that outpatient transport services should get patients to their dialysis as scheduled to avoid their condition deteriorating.

It should also be ensured that appropriate transport services are available by finding out what current transport providers are prepared to provide, and whether there are alternative providers if the current providers will not transport patients infected with COVID-19.


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