IOIBD Update on COVID19 for Patients with Crohn’s Disease and Ulcerative Colitis

IOIBD Update on COVID-19 for Patients with Crohn’s Disease and
Ulcerative Colitis

Update: 26 March 2020

The International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) is the only worldwide organization devoted to Crohn’s disease and ulcerative colitis. There are currently 89 members of IOIBD representing 26 different countries. The mission of the IOIBD is to promote the health of people with inflammatory bowel disease (IBD) worldwide by setting the direction for patient care, education and research. We have taken particular interest in the COVID-19 pandemic and how it might impact our patient population.  There is clearly much more to learn, and our organization is creating a task force focused on developing and updating information and recommendations as the global impact of COVID-19 evolves.

This post replaces prior posts from 11 March 2020 and 4 March 2020.

What are SARS-CoV-2 and COVID-19?

Coronaviruses are a family of viruses that can cause illness from the common cold to more severe diseases. There have been two prior outbreaks of coronaviruses in the last 20 years. First, the Severe Acute Respiratory Syndrome CoronaVirus (SARS-CoV) in 2002-2003 and second, the Middle Eastern Respiratory Syndrome CoronaVirus (MERS-CoV) in 2012. Some of what we learned about transmission and behavior of coronaviruses comes from the experiences with these viral outbreaks. Both of these outbreaks were epidemics but not pandemics and had higher mortality rates than is being seen with the current coronavirus outbreak, which may in fact be why they were contained more easily. The current novel strain of coronavirus named SARS-CoV-2 was first detected in Wuhan, China in December 2019, and when the infection causes symptoms, it is termed the CoronaVirus Disease, 2019 or COVID-19. On March 11, 2020, the World Health Organization classified COVID-19 as a pandemic, meaning that it is worldwide.

How is SARS-CoV-2 transmitted? What is the relationship to COVID-19?

SARS-CoV-2 is primarily transmitted via respiratory droplets produced when an infected person sneezes or coughs and can infect people in close contact (within 6 feet). Touching contaminated surfaces (like shared towels or hard surfaces in bathrooms or other shared spaces) before touching your eyes/nose/mouth might also lead to infection. There is emerging information that intact virus is detectable in stool and a fecal-oral route of transmission is postulated. Most people infected with the virus SARS-Co-2 do not develop the disease called COVID-19, but of those who develop COVID-19, many may require hospitalization and care in an intensive care unit.

How does COVID-19 compare with seasonal influenza?

Both are infectious respiratory illnesses that present with symptoms such as fever, cough, and shortness of breath. Both can lead to serious illness especially in older people and those with prior medical conditions. One difference is that you can get vaccinated for the flu, but there is not a vaccine available yet for COVID-19. There are other differences that are important, too, such as the infectivity of SARS-CoV-2 appears higher than influenza viruses, the number of young people with disease requiring hospitalization is higher with COVID-19, and the mortality rate of COVID-19, while not fully known, appears to be higher than that with influenza as well.

What does this mean for IBD patients?

IBD is a condition of an overactive immune system and is often treated with immune modification or immune suppression to achieve a goal of symptom control and disease modification. IBD patients taking some medications may be more susceptible to infection, but this depends on the type of medications that they are receiving.

To date, there are limited data about patients with IBD who have COVID-19.

What is IOIBD doing to help during the COVID-19 pandemic?

From the early time of the SARS-CoV-2 outbreak, members of IOIBD (and many other healthcare workers involved in the care of IBD patients) have been monitoring the situation and providing our patients with our best advice to stay healthy, both from their Crohn’s disease or ulcerative colitis as well as from the COVID-19 pandemic. While this advice from individual IBD experts is essential, we also recognize that it is of great importance to talk to and learn from one another in order to help our patients and our colleagues around the world.

Such collaboration has resulted in the initial information about SARS-CoV-2 and COVID-19 posted to the IOIBD.org website on 4 March 2020 and an update on 11 March 2020. On 20 March 2020, IOIBD hosted an international webinar of its membership and additional invited expert scientists and physicians to discuss the situation and develop best practices and recommendations to our patients and to our colleagues. In preparation for the 20 March call, participants were invited to respond to statements related to the risk of infection and management of IBD therapies during the current COVID-19 pandemic. The statements covered a variety of clinical scenarios (IBD patients who are not infected with SARS-CoV-2, IBD patients infected with SARS-CoV-2 but who did not develop COVID-19, and IBD patients who develop COVID-19).

During the webinar the group heard from colleagues in different parts of the world and experts who provided information about viral transmission and what is known about infections and available IBD therapies. In addition, the results from the first round of voting were reviewed, and we focused on statements in which there was disagreement or uncertainty.

Subsequent to the 20 March call as per RAND panel protocol, a second round of voting with modified statements was sent to the participants. This post (on 26 March 2020) is a summary report of the results from this final round of voting.

What is a RAND panel?

The RAND/UCLA approach was developed to collect expert opinions in the setting of uncertainty when having to make decisions about complex situations (1). We used this method to address the appropriateness of specific medical interventions or medical decisions related to the COVID-19 pandemic. A series of statements are provided and the respondents rate each of the patient scenarios on a scale of 1 to 9, such that statements rated 1-3 are considered “inappropriate,” 4-6 are “uncertain,” and 7-9 are “appropriate.”

The summary of the IOIBD-COVID-19 RAND panel is provided here. The full data are being submitted for publication in a peer-reviewed journal and will be available soon.

  1. Brook RH. The RAND/UCLA appropriateness method. Clinical practice guideline development: methodology perspectives. Rockville, MD: Public Health Service, AHCR; 1994.

Due to the nature of this rapidly evolving situation, we acknowledge that as we learn more, our understanding of COVID-19 and IBD is likely to evolve and change, and these statements will be modified. These statements are meant to inform clinical decision making and should not replace individualized management and discussions with a patient’s healthcare team.

What’s next?

IOIBD and the invited experts are scheduling weekly updates and ongoing discussions and reviews of available data and will update this site and information for our patients and colleagues on a regular basis.

Where else can information be found?

  1. International registry for IBD patients with COVID-19: covidibd.org
  2. Crohn’s & Colitis Foundation: crohnscolitisfoundation.org/coronavirus
  3. World Health Organization: WHO.int
  4. Centers for Disease Control and Prevention: CDC.gov

 IOIBD Update on COVID-19 for Patients with Crohn’s Disease and Ulcerative Colitis

Update: 26 March 2020

Summary of Statements

These statements represent the summation of expert opinion and should be interpreted in the context of the individual patient and the managing healthcare provider who knows her or him. These are not guidelines and these may be updated as knowledge and the situation evolve.

  1. The risk of infection with SARS-CoV-2 is the same whether a patient has IBD or does not have IBD.
  2. Independent of treatment, patients with Crohn’s disease do not have a greater risk of infection with SARS-CoV-2 than the general population.
  3. Independent of treatment, patients with ulcerative colitis do not have a greater risk of infection with SARS-CoV-2 than the general population.
  4. It is uncertain if active inflammation from IBD increases the risk of getting SARS-CoV-2.
  5. It is uncertain if patients with IBD who are exposed to SARS-CoV-2 have a higher risk of developing COVID-19 compared to patients without IBD.
  6. It is uncertain if patients with IBD who develop COVID-19 have a higher mortality compared to patients without IBD.
  7. Patients with an ostomy are not at increased risk for COVID-19.
  8. Patients with a J pouch are not at increased risk for COVID-19.
  9. Elective surgeries and endoscopies should be postponed at this time.
  10. It is uncertain if healthcare workers with IBD on immune modifying medications working in an environment with known or suspected COVID-19 patients should continue working in that same environment.
  11. Patients with IBD on immune modifying medications should discontinue any non-essential travel.
  12. It is safe to continue infusions in an infusion center, assuming the infusion center has a screening protocol in place.
  13. 5-ASA does not increase the risk of infection with SARS-CoV-2.
  14. 5-ASA does not increase the risk of COVID-19.
  15. Patients taking 5-ASA therapy should not reduce the dose of therapy to prevent SARS-CoV-2 infection.
  16. Patients taking 5-ASA therapy should not discontinue therapy to prevent SARS-CoV-2 infection.
  17. Patients taking 5-ASA therapy should not stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.
  18. Patients taking 5-ASA therapy should not stop therapy if they develop COVID-19.
  19. Budesonide does not increase the risk of infection with SARS-CoV-2.
  20. Budesonide does not increase the risk of COVID-19.
  21. Patients taking budesonide therapy should not reduce the dose of therapy to prevent SARS-CoV-2 infection.
  22. Patients taking budesonide therapy should not discontinue therapy to prevent SARS-CoV-2 infection.
  23. It is uncertain if patients taking budesonide therapy should stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.
  24. It is uncertain if patients taking budesonide therapy should stop therapy if they develop COVID-19.
  25. Prednisone (≥20mg/d) increases the risk of infection with SARS-CoV-2.*
  26. Prednisone (≥20mg/d) increases the risk of COVID-19.*
  27. Patients taking prednisone therapy (≥20mg/d) should reduce the dose of therapy to prevent SARS-CoV-2 infection.
  28. Patients taking prednisone therapy (≥20mg/d) should discontinue therapy (taper as appropriate) to prevent SARS-CoV-2 infection.*
  29. Patients taking prednisone therapy (≥20mg/d) should stop therapy (taper as appropriate) if they test positive for SARS-CoV-2 but don’t have COVID-19.
  30. Patients taking prednisone therapy (≥20mg/d) should stop therapy (taper as appropriate) if they develop COVID-19.
  31. It is uncertain if azathioprine/6-MP increases the risk of infection with SARS-CoV-2.
  32. It is uncertain if azathioprine/6-MP increases the risk of COVID-19.
  33. Patients taking azathioprine/6-MP should not reduce the dose of therapy to prevent SARS-CoV-2 infection.
  34. Patients taking azathioprine/6-MP should not discontinue therapy to prevent SARS-CoV-2 infection.
  35. Patients taking azathioprine/6-MP should stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.
  36. Patients taking azathioprine/6-MP should stop therapy if they develop COVID-19.
  37. It is uncertain if methotrexate increases the risk of infection with SARS-CoV-2.
  38. It is uncertain if methotrexate increases the risk of COVID-19.
  39. Patients taking methotrexate should not reduce the dose of therapy to prevent SARS-CoV-2 infection.
  40. Patients taking methotrexate should not discontinue therapy to prevent SARS-CoV-2 infection.
  41. Patients taking methotrexate should stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.*
  42. Patients taking methotrexate should stop therapy if they develop COVID-19.
  43. It is uncertain if anti-TNF therapy increases the risk of infection with SARS-CoV-2.
  44. It is uncertain if anti-TNF therapy increases the risk of COVID-19.
  45. Patients taking anti-TNF therapy should not reduce the dose of therapy to prevent SARS-CoV-2 infection.
  46. Patients taking anti-TNF therapy should not discontinue therapy to prevent SARS-CoV-2 infection.
  47. It is uncertain if patients taking anti-TNF therapy should stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.
  48. Patients taking anti-TNF therapy should stop therapy if they develop COVID-19.
  49. Vedolizumab does not increase the risk of infection with SARS-CoV-2.
  50. Vedolizumab does not increase the risk of COVID-19.
  51. Patients taking vedolizumab should not reduce the dose of therapy to prevent SARS-CoV-2 infection.
  52. Patients taking vedolizumab should not discontinue therapy to prevent SARS-CoV-2 infection
  53. It is uncertain if patients taking vedolizumab should stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.
  54. It is uncertain if patients taking vedolizumab should stop therapy if they develop COVID-19.
  55. Ustekinumab does not increase the risk of infection with SARS-CoV-2.
  56. Ustekinumab does not increase the risk of COVID-19.
  57. Patients taking ustekinumab should not reduce the dose of therapy to prevent SARS-CoV-2 infection.
  58. Patients taking ustekinumab should not discontinue therapy to prevent SARS-CoV-2 infection.
  59. It is uncertain if patients taking ustekinumab should stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.
  60. Patients taking ustekinumab should stop therapy if they develop COVID-19.
  61. It is uncertain if tofacitinib increases the risk of infection with SARS-CoV-2.
  62. It is uncertain if tofacitinib increases the risk of COVID-19.
  63. Patients taking tofacitinib should not reduce the dose of therapy to prevent SARS-CoV-2 infection.
  64. Patients taking tofacitinib should not discontinue therapy to prevent SARS-CoV-2 infection.
  65. Patients taking tofacitinib should stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.*
  66. Patients taking tofacitinib should stop therapy if they develop COVID-19.
  67. It is uncertain if patients taking combination therapy with an anti-TNF and thiopurine/methotrexate should reduce the dose of the thiopurine/methotrexate to prevent infection from SARS-CoV-2.
  68. Patients taking combination therapy with an anti-TNF and thiopurine/methotrexate should stop the thiopurine/methotrexate if they test positive for SARS-CoV-2 but don’t have COVID-19.
  69. Patients taking combination therapy with an anti-TNF and thiopurine/methotrexate should stop the thiopurine/methotrexate if they develop COVID-19.
  70. Patients taking clinical trial drugs should not discontinue therapy to prevent SARS-CoV-2 infection.
  71. Patients taking clinical trial drugs should stop therapy if they test positive for SARS-CoV-2 but don’t have COVID-19.*
  72. Patients taking clinical trial drugs should stop therapy if they develop COVID-19.
  73. A patient with moderately to severely active Crohn’s disease or ulcerative colitis (new diagnosis or relapsing disease) should be treated with the same therapies you would choose in the pre-COVID-19 era.*
  74. In an IBD patient who tests positive for SARS-CoV-2 and whose IBD meds have been stopped because of this, IBD meds can be restarted after 14 days (provided they have not developed COVID-19).
  75. In an IBD patient who develops COVID-19 and whose IBD meds have been stopped, IBD meds can be restarted after COVID-19 symptoms resolve.*
  76. In an IBD patient who develops COVID-19 and whose IBD meds have been stopped, IBD meds can be restarted after 2 nasopharyngeal PCR tests are negative.

 * These are statements that had a higher degree of disagreement amongst the panelists.

Appendix: What medications are discussed here? This table is for reference to explain the different treatments mentioned in the summary.

THERAPY TYPE ALSO KNOWN AS
5-ASA Asacol, Apriso, balsalazide, Dezicol, Lialda, mesalamine, mesalazine, Pentasa
Budesonide (steroid with limited systemic effects) Entocort, Uceris
Steroids (the dose discussed is oral prednisone and ≥20 mg per day) Prednisone, Medrol, Hydrocortisone
Thiopurines 6-mercaptopurine, azathioprine, Azasan, Purinethol
Methotrexate Trexal, Rheumatrex
JAK inhibitor tofacitinib (Xeljanz)
Anti-TNF adalimumab (Humira, Abrilada, Ajevita, Cyltezo, Hyrimoz, Hadlima), certolizumab pegol (Cimzia), golimumab (Simponi),  infliximab (Remicade, Avsola, Inflectra, Ixifi Remsima, Renflexis)
Anti-IL12/23 ustekinumab (Stelara)
Anti-integrin vedolizumab (Entyvio), natalizumab (Tysabri)
Calcineurin inhibitors (not discussed here) cyclosporine (Gengraf, Neoral, Sandimmune), tacrolimus (Prograf, FK506)
Enteral nutrition (not discussed here)

 

Comments are closed.

Contact IOIBD       |       Webdesign Inmedia