Many IBD patients who develop COVID-19 must stop their medications.
Bethesda, Maryland (April 10, 2020) – Today, the American Gastroenterological Association (AGA) released new COVID-19 guidance for gastroenterologists treating patients with inflammatory bowel disease (IBD):
AGA Clinical Practice Update on the Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary.
While the COVID-19 pandemic is a global health emergency, IBD patients have particular concerns about their risk of infection and management of their medical therapies. This clinical practice update incorporates the emerging understanding of COVID-19 and summarizes the guidance available for patients with IBD and the providers who care for them.
Does the presence of inflammation of the intestine affect the clinical course of patients with COVID-19?
There is limited information as documentation of intestinal inflammation was not routinely assessed in these patients. However, it has been established that while viral RNA has been identified in approximately half of COVID-19 patients, persisting in many even after respiratory samples became negative, there has been no clear association with gastrointestinal symptoms. and the presence of viral RNA in the stool.
Diarrhea (patient-defined) was present in only 10.1% of patients hospitalized with COVID-19 in Wuhan China (16.7% of those in the ICU) 16 ; While another study showed that about half of patients had digestive symptoms as part of their presentation to hospital with COVID-19 and pneumonia, only a third had diarrhea.
Of interest, patients with gastrointestinal symptoms from Zhejiang Province had a much lower incidence of gastrointestinal symptoms (11.45%), reflecting the possibilities of different viral strains reporting differences, or both.
In all of these reports, patients with digestive symptoms more often also had concurrent fever and respiratory symptoms.
Given the prevalence of non-specific digestive symptoms in the population and especially in IBD patients, the clinical implications of this are quite important. Patients who develop new digestive symptoms but do not have fever or respiratory symptoms can be monitored for symptom progression that could guide the timing of SARS-CoV-2 testing, and in patients with IBD, trigger additional treatment adjustments .
What are the outcomes if an IBD patient develops COVID-19?
There is limited data from China and Europe on the outcomes of IBD patients who develop CVOID-19. An international registry (SECURE-IBD18) has been established that collects information on patients with IBD and confirmed (positive) COVID-19.
It is too early to draw definitive conclusions, but of 164 patients reported to the registry at the time of writing, patients with severe IBD and COVID-19 (reported as Physician Global Assessment) are more likely to be hospitalized relative to their IBD or COVID-19 (or both). We anticipate more robust data in the next month or two as cases grow around the world. Established cases should be reported at COVIDIBD.ORG.
Do IBD therapies affect the risk of SARS-CoV-2 infection?
The most common question asked by IBD patients and their providers is “what is done with IBD therapies in patients during the current pandemic, especially those suspected or confirmed to have COVID-19?”
In the absence of outcome data, we must rely on information to date as well as expert guidance during these difficult times. To this end, we have incorporated the general guidance and consensus statements of the British Society of Gastroenterology (BSG) 19 and the International Organization for the Study of Inflammatory Bowel Disease (IOIBD).
We divide the considerations for therapeutic treatment in IBD into three categories:
1) The IBD patient who is NOT infected with SARS-CoV-2.
2) The IBD patient who is infected with SARS-CoV-2 and asymptomatic (e.g., IBD is in remission and has not developed manifestations of COVID-19).
3) The IBD patient who has confirmed COVID-19, with or without active intestinal inflammation or other digestive symptoms.
Recommendations for gastroenterologists and their IBD patients: 1. During this pandemic, IBD patients should continue IBD therapies, including scheduled infusions. 3. Instructions for IBD patients who develop COVID-19 (fever, respiratory symptoms, digestive symptoms, etc.): to. Stop thiopurines, methotrexate, tofacitinib. C. May restart therapies after complete resolution of COVID-19 symptoms. Patients should always talk to their healthcare team before stopping any medication. 4. Clinicians should submit IBD and confirmed COVID-19 cases to the SECURE-IBD registry at COVIDIBD.org. |
This paper, written by leading IBD experts David T. Rubin, Joseph D. Feuerstein, Andrew Y. Wang, and Russell D. Cohen, is published in Gastroenterology by the AGA. This expert commentary was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide a timely perspective on a topic of great clinical importance to AGA members.
