Implications for patients with inflammatory bowel disease (IBD).

The risk of coronavirus infection and severe course is not generally increased in patients with gastroenterologic disease and depends on therapy. An expert panel has published a risk assessment and recommendations for treating CED in the context of the current corona pandemic.

An addendum to the Crohn’s disease and ulcerative colitis S3 guidelines addresses key issues surrounding the care of patients with inflammatory bowel disease (IBD) in the COVID 19 pandemic [1]. For most patients, the condition begins during the school/education years and continues throughout life. It is well known that the risk of infections is increased in patients on immunosuppressive therapy or steroid medication. The implications of this in the context of SARS-CoV-2 have been summarized in practice-oriented recommendations by 68 experts who were involved in the preparation of the currently valid CED guidelines of the DGVS. These refer to the risk of infection, the possible course of the disease and the consequences for the therapy of the underlying disease as well as general measures for infection prevention and adjuvant treatment options. The key messages of these consensus recommendations are as follows:

• CED sufferers are generally not at increased risk for SARS-CoV-2 infection, but these patients should carefully take individual protective measures.
• Patients with IBD and immunosuppressive therapy are at increased risk for SARS-CoV-2 infection and should carefully implement individual protective measures. The degree of risk increase seems to be different for individual immunosuppressants.
• Patients with IBD and SARS-CoV-2 infection are at increased risk for severe COVID-19 disease progression under certain conditions (comorbidities/risk factors). This group of patients should be carefully monitored for rapid deterioration of their disease.
• Patients with IBD and immunosuppressive therapy are generally not at increased risk for severe course of SARS-CoV-2 infection. Immunosuppressive therapy should therefore not be reduced in mild to moderate COVID-19 disease. Exceptions are prolonged therapy with systemic steroids, especially in doses greater than 20 mg prednisone equivalent/day. This should therefore be avoided as far as possible or reduced and terminated as far as clinically justifiable.
• During the SARS-CoV-2 pandemic, biologics therapy with an expected rapid onset of action should be preferred over high-dose systemic steroid therapy in the acute episode.

In patients with severe COVID-19 disease, therapy with thiopurines, methotrexate, and tofacitinib should be paused and resumed after the infection is overcome.

Hospitalized patients with IBD and COVID-19 disease should receive at least prophylactic thromboprophylaxis. In COVID-19 outpatients with IBD, the decision to use thromboprophylaxis should be made generously according to their individual risk profile and concomitant medication.
During the pandemic, patient presentations at health care facilities should be restrictive. CED consultations should continue, taking into account the urgency of presentation and optimizing infection control measures such as spatial distancing and after taking advantage of telemedicine opportunities.

During the pandemic, all endoscopic examinations should take place under special protective measures. The extent of the protective measures should be risk-adapted.

Individual “shared decision making” recommended

Surveys of patients with IBD indicate that they are concerned about an increased risk of infection with SARS-CoV-2 [2]. According to initial epidemiologic data, patients with IBD are generally not at increased risk for COVID-19 disease (Box). The authors of the consensus recommendations in the addendum to the S3 guideline point out that patients’ concerns and fears should be taken seriously and that treatment decisions should be made individually in the sense of “shared decision making”. Discontinuing immunosuppressive therapy or reducing the dose carries the risk of worsening the underlying disease. For example, the European Crohn’s and Colitis Organization (ECCO) assessment published on 3/13/2020 emphasizes that discontinuation or dose reduction for risk reduction of COVID-19 disease is not recommended [3]. In particular, with regard to biologic therapy, the lack of empirical evidence makes it difficult to draw clear conclusions on whether or not, for example, extending infusion intervals is a reasonable option for patients in stable remission [4,5]. With regard to steroid therapy, clearer recommendations are possible. The conclusion in this regard is that systemically acting steroid therapies should be avoided at doses above 20 mg/day. It has been known for some time that such high-dose steroid medication increases the risk of opportunistic infections, including influenza infections and severe pneumonia, and results in a significantly increased frequency of hospitalizations and increased mortality [6–9]. In a large case-control study of 140 000 patients with IBD, steroid medication was an independent risk factor for influenza infection (odds ratio, 1.22; 95% CI: 1.08-1.38) [10]. In this respect, steroid medication, especially at higher doses, should be assumed to be a risk factor for COVID-19 disease, the authors concluded [1].

Literature:

1. Addendum to the S3 guidelines Crohn’s disease and ulcerative colitis: care of patients with inflammatory bowel disease in the COVID-19 pandemic – open questions and answers. Z Gastroenterol 2020; 58(7): 672-692.
2. Grunert PC, Reuken PA, Stallhofer J: IBD in the COVID-19 pandemic – the patients’ perspective. 2020
3. Taskforce: PDCAobotC-E 2020. https://ecco-ibd.eu
4. Papamichael K, Karatzas P, Mantzaris GJ: De-escalation of Infliximab Maintenance Therapy from 8- to 10-week Dosing Interval Based on Faecal Calprotectin in Patients with Crohn’s Disease J Crohns Colitis 2016; 10371-372. doi:10.1093/ecco-jcc/jjv206
5. Giwa AL, Desai A, Duca A: Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians. Emergency medicine practice. 2020; 22: 1-2.
6. Long MD, Martin C, Sandler RS: Increased risk of pneumonia among patients with inflammatory bowel disease The American Journal of Gastroenterology 2013;108(2): 240-248.
7. Orlicka K, Barnes E, Culver EL: Prevention of infection caused by immunosuppressive drugs in gastroenterology Therapeutic advances in chronic disease 2013; doi:10.1177/2040622313485275.
8. Dorrington AM, et al: The historical role and contemporary use of corticosteroids in inflammatory bowel disease. J Crohns Colitis 2020. doi: 10.1093/ecco-jcc/jjaa053.
9. Lichtenstein GR, Feagan BG, Cohen RD: Serious infection and mortality in patients with Crohn’s disease: more than 5 years of follow-up in the TREAT registry The American Journal of Gastroenterology 2012. doi:10.1038/ajg.2012.218
10. Tinsley A, et al: Increased Risk of Influenza and Influenza-Related Complications Among 140,480 Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2018. doi: 10.1093/ibd/izy243
11. Mao R, Liang J, Shen J: Implications of COVID-19 for patients with pre-existing digestive diseases Lancet Gastroenterol Hepatol 20205426-428. doi: 10.1016/S2468-1253(20)30076-5
12. Norsa L, et al: Uneventful course in IBD patients during SARS-CoV-2 outbreak in northern Italy. Gastroenterology 2020. doi: 10.1053/j.gastro.2020.03.062
13. Taxonera C, et al: 2019 Novel Coronavirus Disease (COVID-19) in patients with In-flammatory Bowel Diseases. Alimentary pharmacology & therapeutics. 2020. doi: 10.1111/apt.15804
14. Allocca M, et al: Incidence and patterns of COVID-19 among inflammatory bowel disease patients from the Nancy and Milan cohorts. Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 2020. doi: 10.1016/j.cgh.2020.04.071

GP PRACTICE 2020; 15(9): 32-33