COVID-19 Recommendations Issued for Managing Digestive Disorders

By Marilynn Larkin

March 20, 2020

NEW YORK (Reuters Health) - Two new papers provide guidance for managing patients with inflammatory bowel disease (IBD) and other digestive disorders during the COVID-19 pandemic.

Based on clinical experience and review of the data, Dr. Min-Hu Chen of The First Affiliated Hospital of Sun Yat-sen University in Guangzhou, China and colleagues pinpoint patients at particular risk for infection, including those who are taking immunosuppressive agents, who have active IBD and malnutrition, who are elderly and/or visit the clinic frequently, who have underlying conditions, or are pregnant.

Their key recommendations, as reported in The Lancet Gastroenterology and Hepatology, include:

- Continue current treatment if disease is stable;

- Do not prescribe a new immunosuppressant or increase the dose of the current immunosuppressant;

- Continue biologics such as the anti-TNFs infliximab or adalimumab;

- Continue vedolizumab since the drug is specific for the intestine;

- Continue ustekinumab, but don't start a new prescription, since it requires an infusion;

- Use enteral nutrition if biologics are not accessible;

- Postpone elective surgery and endoscopy;

- Screen for COVID-19 before emergency surgery.

Commenting on the recommendations from China, gastroenterologist Dr. Shannon Lang of NYU Langone's Inflammatory Bowel Disease Center in New York City noted in an email to Reuters Health, "Immunosuppressants such as azathioprine, mercaptopurine, and tofacitinib may affect viral response, though this has not been proven in reference to COVID." Like the authors, she adds that if patients are doing well on their medications, they should stay on them. She added that enteral nutrition is "usually quite difficult for most adult IBD patients" and should not be attempted without physician guidance.

In another paper published this week in Clinical Gastroenterology and Hepatology, Dr. Ryan Ungaro of Mount Sinai Hospital's Feinstein IBD Center in New York City and colleagues provide COVID-19 advice for gastroenterologists and patients, based on currently available information.

"If feasible, clinicians should have a template message with general guidance. for patients, as there is a lot of misinformation out there," Dr. Ungaro told Reuters Health by email. Clinicians can provide handouts with some of the main points from the CDC website or send patients directly to the site (https://www.cdc.gov/coronavirus/2019-ncov/index.html), he suggested.

"If patients have a text or email messaging system, this would also be a good method to distribute the information," he said. "For any office visits or procedures, clinicians should be pre-screening patients over the phone before they come to the office and if they have any concerning symptoms, they should be advised to stay home or go to ER if more severe symptoms (shortness of breath, etc.) arise."

Highlights of the U.S. team's recommendations include:

- Clinicians should use personal protective equipment, including face shields, during endoscopy as the GI tract is a potential route of SARS-CoV-2 infection;

- GI symptoms such as nausea or diarrhea could be an early sign of COVID-19;

- Liver function abnormalities are among the laboratory findings described in COVID-19 patients;

- Physicians should take patient concerns about COVID-19 as an opportunity to review immunization status against vaccine-preventable infections, in particular influenza;

- Good hand hygiene and social distancing remain the primary best means of preventing COVID-19.

Dr. Ungaro noted, "This is a rapidly evolving situation with new information daily. Regularly checking the CDC website and GI society websites (such as the American Gastroenterology Association and American College of Gastroenterology) is important. Social media, in particular Twitter, can be a good source of information as well, but verify information sources."

Dr. Robert Hirten, an assistant professor of medicine at the Icahn School of Medicine at Mount Sinai and a gastroenterologist at its Inflammatory Bowel Disease Center, told Reuters Health by email, "The recommendations from both articles are in line with each other...and are applicable to all people who have IBD."

"The biggest take home message from both articles is that this is a rapidly evolving situation," said Dr. Hirten, who was not involved in the Mount Sinai guidance. "While both sets of recommendations are based on the most up-to-date information at the time they were written, we need to be using the most current information available to guide how we are managing all people, including those who have IBD."

Like Dr. Ungaro, he noted, "It is very important for both patients and doctors to stay (current with) the most recent recommendations from the CDC and national gastroenterology societies. This assures that we are using the most up-to-date information available when we make medical decisions."

Clinicians are encouraged to report their IBD patients who test positive for COVID-19 to a new web-based registry called SECURE-IBD (Covidibd.org).

Dr. Chen did not respond to requests for a comment.

SOURCES:

http://bit.ly/2Wu9j02 The Lancet Gastroenterology, online March 11, 2020.

http://bit.ly/3dgzVHJ Clinical Gastroenterology and Hepatology, online March 17, 2020.

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