Leading experts have drafted new guidelines to aid gastroenterologists in the management of patients with inflammatory bowel disease (IBD) during the COVID-19 pandemic, according to an American Gastroenterological Association (AGA) press release.
The guidance, “AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary” was published in the journal Gastroenterology.
The COVID-19 pandemic is a global health emergency, and patients with IBD are particularly concerned about their risk of infection as they are often prescribed immunosuppressive or immune-modifying therapies to control the chronic inflammation that characterizes IBD. Some of these therapies can increase the risk for viral infections. Moreover, the use of medical facilities by IBD patients also poses an additional risk for infection.
Nonetheless, despite the potential for an increased risk, the limited available data indicates “that patients with IBD do not appear to have a baseline increased risk of infection with SARS-CoV-2 or development of COVID-19,” the researchers wrote.
It remains unclear if gut inflammation in IBD is a risk factor for infection with SARS-CoV-2, the virus responsible for the COVID-19 pandemic. As such, experts recommend that “patients with IBD should maintain [disease] remission in order to reduce the risk of relapse and need for more intense medical therapy or hospitalization.”
IBD patients’ most frequent question is linked to what they should do concerning their therapeutic regimen during the pandemic, especially for those suspected of or confirmed to have COVID-19. Since the data available so far is limited, the experts drafted personalized recommendations according to whether IBD patients are negative, suspected, or confirmed with COVID-19.
Those who are not infected with SARS-CoV-2 should continue their IBD treatment. Their goal is to achieve sustained remission, defined as both a remission of clinical symptoms and control of inflammation.
Similar to the recommendations to the general population, patients with IBD should maintain social distancing and work from home whenever possible. They should also follow the recommendations for meticulous hand hygiene.
Another concern of both patients and physicians is the need to go to infusion centers to receive infusible IBD therapies, such as infliximab (marketed as Inflectra, Remicade, and Remsima, among others), Janssen‘s Stelara (ustekinumab), and Entyvio (vedolizumab) by Millennium Pharmaceuticals (part of Takeda Pharmaceuticals).
The recommendation supports the use of infusion centers as long as they have protocols in place for COVID-19 screening. While infusions at home may seem like an alternative to limit exposure, this was not recommended by the experts.
“There are many uncontrolled variables, and there is a serious risk that a nurse-provider traveling from home to home may become infected, and act as a vector to other patients,” the team wrote.
For IBD patients infected with SARS-CoV-2 but without symptoms, experts recommend that their dose of prednisone — the most commonly prescribed corticosteroid — be lowered to less than 20 mg/day, or that they transition to budesonide, a glucocorticoid, when possible.
Immunosuppressive therapies — thiopurines, methotrexate, and Pfizer’s Xeljanz (tofacitinib) — should be halted temporarily.
Dosing with immunotherapies based on monoclonal antibodies, such as anti-tumor necrosis factor (TNF) therapies, Stelara, and Entyvio, should be delayed for two weeks while monitoring for COVID-19. If during this period, patients do not develop symptoms, or, if available, follow-up viral testing is negative, patients can resume these therapies.
IBD patients with confirmed symptoms of COVID-19 represent the most challenging group of patients to be managed. The severity of both IBD and COVID-19 should be taken into account for a careful risk-benefit assessment regarding treatment for both conditions.
Special attention is required when considering the potential impact to the immune system of IBD treatments, and whether it may worsen outcomes of COVID-19.
“In regard to the IBD therapies, aminosalicylates, topical rectal therapy, dietary management, and antibiotics are considered safe and may be continued,” the researchers wrote.
Budesonide is also considered safe, but administration of systemic (whole-body) corticosteroids “should be avoided and discontinued quickly,” they added. Thiopurines, methotrexate, and Xeljanz should also “be discontinued during the acute illness. Anti-TNF therapies and ustekinumab [Stelara] should also be held during the viral illness.”
In IBD patients with COVID-19 and digestive symptoms, investigating the cause of the digestive symptoms “is critically important,” the experts wrote. “If the results suggest relapsing IBD, treatment of the IBD should be based on the activity of the inflammation and severity of the IBD.”
They also emphasized that endoscopies during the COVID-19 pandemic should only be done when they can lead to urgent changes in treatment plan.
Finally, experts advise clinicians to submit cases of IBD and confirmed COVID-19 to the SECURE-IBD registry at COVIDIBD.org
The guidelines were developed by IBD experts David T. Rubin, MD, and Russell D. Cohen, MD, at the University of Chicago Medicine Inflammatory Bowel Disease Center; Joseph D. Feuerstein, MD, at the Beth Israel Deaconess Medical Center; and Andrew Y. Wang, MD, at the University of Virginia.
The report was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board.
Rubin has received grant support from Takeda, and Cohen serves on the speakers’ bureau for Abbvie and Takeda. Both experts serve as consultants for several pharmaceuticals.