COVID-19: Latest advice – 7th June 2020


by JD

By Dr Steven Mann,  Consultant Gastroenterologist, 7th June 2020

Implications of having Inflammatory Bowel Disease during the Covid-19 pandemic.

In the UK, there are over 0.5 million people with IBD, namely Crohn’s disease or ulcerative colitis. Many of these patients will be on immunosuppressant drugs to control the gut inflammation. Over the last 3 months, patients have expressed concerns about the impact that IBD or the medication may have on their vulnerability to Covid-19 or its complications, or the impact that Covid may have on their own IBD. These have also been challenging times for patients being able to access their local IBD service due to service reconfiguration, cessation of face to face clinics, redeployment of staff to Covid duties, sick leave or isolation for health care professionals, etc.

Medication in IBD and Covid

The established risk factors for a worse outcome in Covid infection include older age, male sex, diabetes, obesity, and underlying cardiac or respiratory diseases. IBD per se does not increase the risk of acquiring Covid-19. The drugs used to treat IBD such as azathioprine, mercaptopurine, methotrexate or any of the biologics do not seem to confer any greater risk to the patient and the BSG and ECCO both advise patients to continue their medication. On the contrary, active disease does confer an increased risk of infection both in the community and in hospital, so stopping any medication should be discouraged to avoid the risk of a flare-up.

Do patients need to be shielded?

It appears that many patients have had letters or text messages form NHS sources advising them to shield for 12 weeks. The BSG has categorised patients into mild, moderate and high risk and these guidelines were published early in the outbreak and still hold true today. Most patients fall into moderate or lowest risk groups.

Low Risk- ‘social distancing’ as advised for the population in general.

Patients on the following medications:

► 5-ASA

► Rectal therapies

► Orally administered topically acting steroids (budesonide or beclometasone)

► Antidiarrhoeals (eg, loperamide)

Moderate Risk- ‘stringent social distancing’

  1. Patients on the following medications

– Anti-TNF (infliximab, adalimumab, golimumab, certolizumab) monotherapy

– Biologic plus immunomodulator in stable patients

– Ustekinumab

– Vedolizumab

– Thiopurines (azathioprine, mercaptopurine)

– Methotrexate

– Janus kinase (JAK) inhibitors (tofacitinib)

– Prednisolone less than 20mg/day

  1. Patients with moderate to severe disease activity not on the medication listed here

Highest Risk- ‘shielding’

  1. IBD patients who either have a comorbidity (respiratory, cardiac, hypertension or diabetes mellitus) and/or are ≥70 years old and are on any ‘moderate risk’ therapy for IBD (per middle column) and/or have moderate to severely active disease
  1. IBD patients of any age regardless of comorbidity and who meet one or more of the following criteria:

– Intravenous or oral steroids ≥20mg prednisolone or equivalent per day (only while on this dose)

– Commencement of biologic plus immunomodulator or systemic steroids within previous 6 weeks

– Moderate to severely active disease not controlled by ‘moderate risk’ treatments

Drug information for Covid

  1. Steroids

– avoid if possible; shield if on a dose of more than or equal to prednisolone 20mg/day

-consider rapid tapering

-do not stop suddenly

-consider use of Budesonide in both Crohn’s and colitis

-if infected with the SARS-CoV-2, try and reduce prednisolone dose to less than 20mg/day or switch to Budesonide if possible

  1. Immunomodulators

-no evidence for increased risk of Covid-19 infection

-if infected with the SARS-CoV-2,withhold the drug temporarily during the acute illness until 7-14 days after the illness

  1. Anti TNF agents

-no evidence for increased risk of Covid-19 infection

– consider initiation as monotherapy (without addition of azathioprine)

-if infected with the SARS-CoV-2, delay the dose for 2 weeks after the acute illness

  1. Ustekinumab (Stelara)

-no evidence for increased risk of Covid-19 infection

-if infected with the SARS-CoV-2, delay the dose for 2 weeks after the acute illness

  1. Vedolizumab

-no evidence for increased risk of Covid-19 infection

-if infected with the SARS-CoV-2, delay the dose for 2 weeks after the acute illness

  1. Tofacitinib

-no evidence for increased risk of Covid-19 infection

-if infected with the SARS-CoV-2, delay the dose for 2 weeks or until the acute illness has resolved

  1. Mesalazine

-no evidence for increased risk of Covid-19 infection

Could IBD Therapies be protective against Covid-19? 

There is some discussion in the literature that the sickest patients who end up on Intensive Care and needing ventilation have a heightened immune reaction the virus, and it is that overreaction that leads to complications. It has been postulated that biologics may protect against this abnormal immune response by dampening down the ‘overreaction’. This is under investigation and data being collected on an International Registry may answer this in due course (SECURE-IBD).

If patients wish to avoid attending the hospital or GPs are not doing blood tests, is that a concern on immunomodulators?

Under normal circumstances, patients on azathioprine, mercaptopurine and methotrexate will have blood test monitoring every 3 months or 2 months (methotrexate). In order to reduce the footfall in hospital or GP surgeries and in the interest of patient safety, there is a new extended monitoring recommendation for use during the Covid-19 pandemic. This allows for 6-monthly blood checks for patients on those drugs when they have been on a stable dose for some years or more than 6 months (methotrexate).

When can I have the colonoscopy that was advised before lockdown?

Following the cessation of all non-essential or non-emergency endoscopy in March 2020, hospitals are now working through processes to restart the service. There is a huge backlog of cases including many IBD patients.

Each Trust is responsible for implementing an infection control pathway that minimises any risk to the patient of catching coronavirus, but also of bringing it into the endoscopy unit. Guidelines have been published to facilitate this pathway. The capability and capacity to restore endoscopy practice will vary across different hospitals.

Patients will be screened with questionnaires and many units will swab patients 3-4 days prior to the procedure. Some units will be requesting that patients self isolate for 7 or 14 days pre-procedure.

IBD patients with a suspected new diagnosis will generally be permitted to have their endoscopy during this recovery phase in addition to patients who are being considered for escalation of therapy such as requiring biologics.

Routine surveillance of colitis patients will be deferred to beyond this recovery phase.

Top 10 tips for everyone with inflammatory bowel disease during the COVID-19 pandemic (BSG)

  1. We will do everything we can to keep you safe and well during the COVID-19 pandemic. Note that hospitals are undergoing massive reorganisation to prepare to care for those with serious infection.
  2. Don’t stop your medication; preventing disease flares is a priority. We want to keep you out of hospital if possible, but if you are unwell, we will be there for you.
  3. Ensure you have a good supply of medication should you need to self-isolate or shield yourself. Do not take steroids (prednisolone) from your general practitioner without discussing with your local inflammatory bowel disease (IBD) team.
  4. Contact your local IBD team via telephone or email helplines if you are experiencing a flare.
  5. Wash your hands frequently and avoid touching your face; this goes for everyone.
  6. Work from home if possible, and avoid non-essential travel and contact with people who are currently unwell.
  7. Stop smoking, as this increases the risk and severity of COVID-19 infection, and avoid non-steroidal antiinflammatory drugs (eg, ibuprofen).
  8. Government guidelines on self-isolation and social distancing are changing rapidly so please visit www.gov.uk and www.nhs.uk to keep up to date. (If you are unclear on your level of risk, contact your local IBD helpline for further advice).
  9. If you, or a household member, develop a continuous cough, flu-like symptoms OR fever you should:
    a) follow the government’s recommendations about self isolation and household quarantine
    b) if you test positive for COVID-19 you should contact your IBD team
    c) stop taking medicines in the moderate risk column of listed drugs above. Steroids should be tapered with advice from the IBD team and not stopped abruptly. Fourteen days after your symptoms have resolved, or if a household member is affected, the household quarantine period ends, contact your local IBD team for advice regarding restarting your medication.
    d) if you feel you cannot cope with your symptoms at home, or your condition gets worse, or your symptoms do not get better after 7 days, then use the NHS 111 online coronavirus service. If you do not have internet access, call NHS 111. For a medical emergency dial 999.
  10. Take care of yourself but also be kind and considerate to others in these difficult times

Since the infection is dynamic and knowledge and evidence are growing rapidly, some of this guidance will be updated as necessary.

 

Other links:

Crohn’s and Colitis UK have summarised the implications of the new UK government shielding guidelines that came into effect on 1st June 2020. The summary can be found here: https://www.crohnsandcolitis.org.uk/news/advice-for-people-with-crohns-and-colitis-self-isolation-social-distancing#new-shielding.

An international database called ‘Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD)’ (https://covidibd.org/) has been collecting data to assess the impact of COVID-19 infection in patients with IBD. An article has been published in the leading journal Gastroenterology including data from 525 patients with IBD infected with COVD-19. A summary of the article can be found here: https://journalsblog.gastro.org/corticosteroids-but-not-tnf-antagonists-associate-with-adverse-covid-19-outcomes-in-patients-with-inflammatory-bowel-diseases/. Using the database, researchers found that in IBD patients increasing age, comorbidities (having other medical conditions) and corticosteroids but not anti-TNF medications were associated with severe COVID-19 infection. Further research is required to understand how these factors contribute.

Watch a recording of the Catherine McEwan Foundation IBD COVID-19 Q&A with Consultant Gastroenterologist Prof. Charles Lees and IBD Specialist Nurse Janice Fennell from 27th May 2020 here: https://www.facebook.com/watch/?v=563445997698539