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Inflammatory bowel disease (IBD) patients who develop COVID-19 coronavirus infection should delay their biological therapies, restarting them once symptoms subside, said a clinical practice update from the American Gastroenterological Association (AGA).

IBD patients who test positive for SARS-CoV-2, the virus that causes COVID-19, but have not developed the illness itself should hold off on thiopurines, methotrexate, and tofacitinib (Xeljanz), as well as biological therapies, for 2 weeks while monitoring for COVID-19 symptoms, according to David T. Rubin, MD, of the University of Chicago, and colleagues .

But patients shouldn't stop medications on their own without getting their doctors' approval, the authors emphasized.

They noted that patients with IBD are not at increased risk of COVID-19 infection, though they added "it is unclear if inflammation of the bowel per se is a risk for infection with SARS-CoV-2, but it is sensible that patients with COVID-19 should maintain remission in order to reduce the risk for relapse and more intense medical therapy or hospitalization."

Importantly, patients with IBD who do not have COVID-19 should continue with their therapies, as well as follow the general recommendations for avoiding infection, such as frequent handwashing and social distancing, the authors wrote.

Patients with IBD can continue visiting infusion centers for delivery of therapies, such as infliximab (Remicade), ustekinumab (Stelara), and vedolizumab (Entyvio), provided the centers have recommended COVID-19 screening protocols in place. Rubin and colleagues also did not recommend switching to home infusions, as "there are many uncontrolled variables," such as a nurse-provider traveling from home to home could unknowingly infect patients.

The guidance addressed two specific scenarios for patients with IBD: testing positive for SARS-CoV-2 without symptoms and developing COVID-19.

Even without "manifestations" of COVID-19, the authors advised actively moving patients to lower doses of prednisone (less than 20 mg/day) or transitioning to budesonide, if possible. Monoclonal antibody therapies should be delayed for 2 weeks, though they may be restarted if a patient has not developed manifestations of COVID-19 at that time.

For a patient with IBD and manifestations of COVID-19, the authors acknowledge "challenges" in clinical management, noting aminosalicylates, topical rectal therapy, dietary management, antibiotics, and likely oral budesonide are considered safe, but systemic corticosteroids should be discontinued quickly, if possible. The authors said medications may be restarted following complete symptom resolution, if follow-up viral testing is negative, or "serologic tests demonstrate the convalescent stage of illness."

However, in all cases, they emphasized the importance of "risk/benefit assessments" when balancing treatments for COVID-19 and escalating treatments for IBD.

The guidance also cited the lack of "clear association" with GI symptoms of COVID-19 (though this has been reported in the literature) and presence of viral RNA in stool, as well as the lack of data for clinical course of COVID-19 among patients with IBD. Rubin and colleagues did, however, reference limited data from , which found patients with severe IBD and COVID-19 are more likely to be hospitalized for both conditions. They also encouraged clinicians to report their cases to this registry.

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