Hospitalization for IBD should not be delayed in pandemic: experts

Last Updated: 2020-08-05

By Will Boggs MD

NEW YORK (Reuters Health) - Hospitalization of patients with severe or complicated inflammatory bowel disease (IBD) should not be delayed during the COVID-19 pandemic, according to recommendations from the International Organization for the Study of IBD (IOIBD).

Experts agree that hospital admissions of IBD patients should be limited to reduce the risks of coronavirus transmission and to ensure that there is sufficient hospital capacity to care for patients with COVID-19, but delaying hospitalization of IBD patients with severe or complicated disease can increase their risk of poor outcomes.

Dr. David T. Rubin of the University of Chicago Medicine IBD Center and colleagues working on behalf of IOIBD developed recommendations regarding hospitalization of IBD patients, either for active or complicated IBD or severe COVID-19 disease, and for the management of IBD patients according to their SARS-CoV-2 infectious status.

IBD patients do not appear to face an increased risk of becoming infected with SARS-CoV-2, they say, but when infected they may have an increased risk of poor outcomes, which may be driven by medications, gastrointestinal inflammation, associated comorbidities, or IBD itself.

According to the expert panel, patients with severe or complicated disease or with emergencies should be evaluated and admitted as they were prior to the pandemic.

On the other hand, patients with less active disease who would ordinarily be admitted for medically resistant disease should not be admitted electively at this time, the authors write in a their report, published in the Journal of Crohn's and Colitis.

The recommendations encourage rapid access to outpatient evaluation and outpatient treatment escalation for these patients and, where available and appropriate, telemedicine options.

Patients requiring hospitalization should be tested for SARS-CoV-2 before admission, where possible, and they should be assigned to a single room until the results of SARS-CoV-2 testing are available.

Patients testing positive for SARS-CoV-2 should be isolated and cared for as are other patients admitted with COVID-19.

Treatment of IBD in patients with SARS-CoV-2 should be considered in the context of the severity of COVID-19. Given the increased hypercoagulability associated with severe COVID-19, anticoagulation prophylaxis should be considered, according to the authors.

Surgery for imminently life-threatening conditions should proceed as clinically indicated, whereas surgery for IBD patients with dysplasia or cancer should be postponed.

The document provides a table of considerations of the treatment of IBD in the setting of COVID-19 according to IBD status, SARS-CoV-2 status, and outpatient or inpatient status.

"The usual management of IBD is strongly impacted by the COVID-19 pandemic, and must be adapted over time according to the local situation and prevalence of COVID-19," the authors conclude. "The objectives of these recommendations are to reduce the risks of contamination, to provide an optimal management of COVID-19 in IBD patients, and to best manage IBD according to SARS-CoV-2 infectious status."

"These recommendations, based on our limited current knowledge on COVID-19, will be updated over time according to a better knowledge of the disease," they note.

In a related paper in the journal, Dr. Laurent Peyrin-Biroulet of Nancy University Hospital, University of Lorraine, in Vandoeuvre-les-Nancy, France, and colleagues on the European Crohn's and Colitis Organization's COVID-19 task force provide 10 "do's and don'ts" regarding IBD management during the COVID-19 outbreak.

A number of general measures aim to reduce the likelihood of contracting COVID-19 (or influenza or pneumococcal pneumonia), including updated vaccination, limited contact with infected people, use of facemasks, and limited travel.

As most professional bodies have recommended, the task force recommends continuation of most IBD treatments in patients without symptoms suggestive of COVID-19.

For IBD patients who are SARS-CoV-2-positive, the experts recommend postponing administration of biologics, discontinuation or reduction of doses of corticosteroids, discontinuation of azathioprine/mercaptopurine, and discontinuation of JAK inhibitors.

Patients who experience an IBD flare should be tested for SARS-CoV-2 and treated according to standard guidance unless they are positive. Subcutaneous medications and home delivery services can be used to minimize hospital visits.

The task force agrees with the IOIBD experts that surgery in life-threatening situations should not be delayed, but that surgery can be postponed in uncomplicated IBD. Surgical staff should use N95 respirators as a minimal requirement.

Other topics considered by the task force include management of IV infusion clinics during the pandemic, personal protective equipment for patients and physicians, management of outpatient IBD clinics, whether IBD patients should continue working, and the use of nonurgent endoscopy during the pandemic.

"A goal should be to treat active disease and maintain remission, while adopting the same protective measures as the general population," the task force concludes.

Dr. Britt Christensen of The Royal Melbourne Hospital, in Melbourne, Australia, who recently reviewed the prevention, diagnosis, and management of COVID-19 in IBD patients, told Reuters Health by email, "A really important point is the coagulation risk with both IBD and COVID-19 - make sure this is managed aggressively in admitted patients, taking into account both IBD and COVID-19 risk."

"A lot is unknown," she said. "Protect your team and your patients from COVID-19, but make sure you still manage the patients' issues as they arise to prevent any long-term complications."

"Prevent hospital admission to avoid these concerns," suggested Dr. Christensen, who was not involved in the two reports. "Make sure patients are compliant with meds; do not hesitate on escalating therapy when needed; and make sure to keep a close eye on patients via telehealth."

Neither Dr. Rubin nor Dr. Peyrin-Biroulet were available for comment by press time.

SOURCE: https://bit.ly/2PqEdBP and and https://bit.ly/2C1pYjQ Journal of Crohn's and Colitis, online July 29, 2020.