Patients should continue IBD treatment during the COVID-19 pandemic

Last Updated: 2020-04-20

By Will Boggs MD

NEW YORK (Reuters Health) - Patients with inflammatory bowel disease (IBD) should continue their treatment during the COVID-19 pandemic, according to experts and international consensus.

"We can't say enough how important it is that patients do what they can to stay healthy; that means staying on their maintenance therapy and taking other precautions right now, including strict social distancing," Dr. David T. Rubin of the University of Chicago told Reuters Health by email.

"We do not think having IBD is a risk for getting infected, nor do we have evidence that the immune-based therapies we use to control Crohn's disease (CD) and ulcerative colitis (UC) are dangerous," he said, "but we certainly do know that stopping maintenance medications will result in relapses of these chronic conditions, which will then result in other challenges, like loss of response to therapies, need for corticosteroids, and strain-limited medical resources."

Dr. Ruben and colleagues address the management of IBD during the COVID-19 pandemic in two new reports in Gastroenterology. The first is a clinical practice update from the American Gastroenterology Association and represents current expert opinions on the subject.

While patients with CD and UC have the potential for increased risk of infection, the limited available data suggest that they do not have an increased risk of developing COVID-19.

While IBD without SARS-CoV-2 infection should stay on their therapies with the goal of sustaining remission, the authors advise, those who are infected but have no manifestations of COVID-19 should be moved to lower doses of prednisone or transitioned to budesonide when feasible, and thiopurines, methotrexate and tofacitinib should be withheld temporarily.

Monoclonal antibody therapies should have their dosing delayed for two weeks while monitoring for development of COVID-19. Patients who don't develop manifestations of COVID-19 should be able to restart therapy after two weeks.

For patients with IBD who have confirmed COVID-19, medical therapy should be adjusted with a focus on reducing immune suppression during acute viral replication in an effort to reduce the likelihood of complications.

Aminosalicylates, topical rectal therapy, dietary management, oral budesonide and antibiotics are safe and may be continued. Other systemic treatments, especially corticosteroids, should be discontinued during the acute illness, according to the report.

In patients with moderately to severely active IBD who have confirmed COVID-19, the risks and benefits of escalating IBD therapy should be carefully weighed against the severity of the COVID-19 infection.

In order to increase the knowledge base about COVID-19 in IBD patients, the authors request that cases of IBD and confirmed COVID-19 be submitted to the SECURE-IBD registry at COVIDIBD.org.

Endoscopic procedures should be delayed unless they will urgently change management.

The second report is the result of an international meeting convened to discuss the management of patients with CD and UC during the COVID-19 pandemic.

The 26 statements endorsed by the participants are in essential agreement with the clinical practice update from the American Gastroenterology Association.

The participants also agreed that patients in clinical trials should continue those therapies unless they become infected by SARS-CoV-2 or develop COVID-19, and most felt that it was appropriate to discontinue the clinical-trial drug if a patient tests positive for SARS-CoV-2 or develops COVID-19.

Dr. Rubin explained, "The recommendation to hold immune therapies in the setting of a known infection or development of COVID-19 on the surface makes sense but there are two realities that must be considered: 1) the half-lives of most of our IBD therapies are long enough that stopping them probably has little impact on the patient's immune system in the time it takes for COVID-19 to run its course, and 2) it may be somewhat counter-intuitive, but in the inflammatory phase of the illness some of our anti-cytokine therapies may actually be helpful, and are being studied now as potential treatments. So, our colleagues do need to appreciate that while we are making educated recommendations based on what we have learned about SARS-CoV-2 and other viral illnesses in our patients, there is much we still do not yet know."

"Fortunately, there is unprecedented international collaboration in the IBD community that other specialties are now emulating (celiac, rheumatoid arthritis, etc.)," he said.

Dr. Rubin advised, "Communicate with your patients in systematic and reassuring ways, but do communicate. They need to hear from us about what to do and that we are working together and are available to them."

Dr. Silvio Danese of Humanitas University, in Milan, Italy, who recently reviewed the management of IBD during COVID-19 but was not connected to the new reports, told Reuters Health by email that "we are still learning." He endorses following the current recommendations of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), which can be found at https://bit.ly/2XRb0VS.

SOURCE: https://bit.ly/3ewLIT9 and https://bit.ly/2VEM2X0 Gastroenterology, online April 10 and 6, 2020.