Direct management :
- If immunosuppressants are taken, a careful monitoring should be offered if the patient show signs and symptoms suggestive for Covid-191.
- Temporarily withhold immunomodulators seems to be a reasonable strategy2-3.
- However, in a systematic review, 27% of patient who discontinued TNFa-inhibitor had IBD relapse after one year. This could lead to higher frequentation medical institutions and could be at higher risk of COVID-19 infection2.
- If patients are infected with SARS-CoV2 without manifestations of COVID-19 and take prednisone, they should be moved to lower doses (<20 mg/d) or transited to budesonide4.
- High dose of steroids is a risk factor for respiratory tract infection and opportunistic infection in IBD5.
- Topical rectal therapy, dietary management and antibiotics should be continued and are considered safe4.
- Covid-19 patients should restart taking their medications if there is no symptoms after 2 weeks or symptoms have completely resolved or after 2 nasopharyngeal PCR negative tests3,4,5.
- If patients are hospitalized for IBD and also has incidentally COVID-19, standard algorithms for hospitalized patients with IBD should be followed4.
- Limiting IV steroids to 3 days is suggested4.
- Cytomegalovirus PCR testing should be done to avoid need for colonoscopic procedures and ganciclovir should be started if results show active inflammation4.
Table 1: Recommendations for medications provided by the IOIBD Panel 3
|Therapy class||Discontinue therapy if patients:|
|Test + for SARS-CoV2 but do not have COVID-19||Develop COVID-19|
|Oral prednisone >20mg/d||Appropriate||Appropriate|
|Calcineurin inhibitors (tacrolimus or ciclosporin)5||–||Appropriate5|
Special considerations regarding possible effects of IBD therapies on COVID-19:
- Potential antiviral activity against MERS and SARS might be present when thiopurines (6-MO and 6-thioguanine) are used. This has been shown in vitro, but considering it has not been tested on patients, no data is available yet3.
- However Lymphopenia can occur from that drug and COVID-19 patients who have lymphopenia have a worse prognosis3.
- Anti-TNF therapy could have an impact on viral immunity because of its small increased risk of herpes zoster and hepatitis B reactivation3.
- However, TNF production by CD4+ T cells is associated with severe SARS-CoV, inhibition of TNF could be useful for cytokine release syndrome which can occur in severe infection.
- Tocilizumab may reduce the severity of ARDS and it is currently being tested3.
- Baricitinib, a Janus kinas inhibitor, could interfere with the virus entering cells by inhibiting endocytosis4.
This data comes from 5 different publications. Monteleone G., et al wrote a Viewpoint to present an overview of factors and mechanisms of how SARS-CoV-2 could infect the cells and identify links with IBD. Bilal S., et al present a Letter to Editor about management of IBD. Rubin DT., et al have written a manuscript reformatted as a Commentary to reunited the opinion of 89 experts of The international Organization for the Study of Inflammatory Bowel Diseases (IOIBD). They have summarized the management of IBD patient in the COVID-19 pandemic. Rubin DT, Feuerstein JD., et al present an expert commentary to review emerging evidence and provide expert recommendations for the management of IBD patients. Kennedy NA et al present a guidelines from British Society of Gastroenterology for the management of IBD.
- Monteleone G., Ardizzone S. (March 26, 2020). Are patients with inflammatory bowel disease at increased risk for Covid-19 infection? Journal of Crohn’s and Colitis, Oxford academic. https://doi.org/10.1093/ecco-jcc/jjaa061
- Bilal S., Fatima H., A Ghouri Y. (April 4, 2020). Management of Inflammatory Bowel Diseases in the Wake of COVID-19 Pandemic. Wiley Online Library, Journal of Gastroenterology and Hepatology. https://doi.org/10.1111/jgh.15056
- Rubin DT., Abreu MT., Rai V., et al. (April 06, 2020). Management of Patients with Crohn’s Disease and Ulcerative Colitis During the COVID-19 Pandemic. Science Direct Journals & books. https://doi.org/10.1053/j.gastro.2020.04.002
- Rubin DT, Feuerstein JD, Wang AY, Cohen RD. (April 10, 2020). AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary. American Gastroenterology Association, Gastroenterology. doi: https://doi.org/10.1053/j.gastro.2020.04.012.
- Kennedy NA, Jones G, Lamb CA, et al. (April 17, 2020). British Society of Gastroenterology guidance for management of inflammatory bowel disease during the COVID-19 pandemic. BMJ journals. doi: 10.1136/gutjnl-2020-321244