International Group Offers Reassuring Guidance for Managing IBD Patients During COVID-19

David A. Johnson, MD


April 27, 2020

This transcript has been edited for clarity.

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Patients with inflammatory bowel disease (IBD) are often taking a variety of immunosuppressants and biologic therapies that can potentially complicate the immune system. This has led many of us to wonder what to do with these patients during the continued COVID-19 global pandemic. I'd therefore like to offer my kudos to the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) for their heroic effort of stepping up to answer this question for us in a new publication.

The IOIBD consists of approximately 80 physicians from 26 countries. When the IOIBD's annual meeting was postponed in mid-March due to COVID-19, the group quickly pivoted to hold two webinars to create consensus statements on the treatment of IBD during this pandemic. They established 76 statements during their first webinar. On the follow-up webinar, they applied a Delphi panel approach to identify 26 of these statements as appropriate, 19 as uncertain, and 31 as inappropriate. I want to highlight some of the guidance that this expert group has put together.

There is good news. The group reported that patients with IBD are not thought to be at an increased risk as it relates to the SARS-CoV-2 virus or the resulting COVID-19 disease. This is important because it is now recognized that this virus needs the angiotensin-converting enzyme 2 (ACE-2) to enter the cell. ACE-2 is found in the upper respiratory tract and also in the gastrointestinal tract, particularly in the small and large intestines. Despite that, this is not associated with an increased concern in patients with IBD.

The group also supported postponing any elective procedures at this time. That's intuitive and something we're now generally doing across the board.

For patients with IBD who are also positive for COVID-19, the group recommended withholding their medications for 2 weeks and then restarting when appropriate after symptom resolution. This is a general approach that we already employ when patients have infections.

What I'd consider the truly important "meat on the bone" of this guidance document related to medical therapy. The group recommended reducing or withdrawing steroids to proactively prevent the risk for SARS-CoV-2 infection. However, the group rated as "uncertain" the statement that patients receiving combination therapy with a biologic and an immunosuppressant should similarly have it removed or reduced to minimize the risk for infection. Certainly, if they do become infected, then it would be appropriate to remove an immune modulator.

We have a number of patients participating in ongoing clinical trials of IBD medications. The group stated that it was still appropriate for such patients to stay in these study protocols provided that they weren't positive for SARS-CoV-2 infection or COVID-19. They also stated that it was appropriate to discontinue the study treatment if a patient became positive for the virus, although it was a mixed recommendation with some disagreement from the reviewers.

How IBD Treatments May Interact With This Novel Virus

Another key message of this guidance document related to infusions and injections. The bottom line was that the group agreed that it was safe for patients to continue at an infusion center, if it had put in place appropriate SARS-CoV-2 and COVID-19 screening protocols. And obviously, the recommendation is to continue injections done at home.

The group noted that it is also particularly important to consider the half-life of the IBD medications we typically use. As a general rule, it takes about 5.5 biologic half-lives to clear the system or at least to get to low levels of detectable drug.

The variety of drugs we employ have considerably different half-life ranges. The approximate half-life is 7 days for thiopurines, 24 hours for corticosteroids, a quick 6 hours for methotrexate, and an even more rapid 3-6 hours for tofacitinib. The half-life is comparatively longer when you look at the injectable and infusion-based medications. The approximate half-life is 10-20 days for adalimumab, 7-12 days for infliximab, 19 days for ustekinumab, and 25 days for vedolizumab.

When you multiply those numbers of days by 5.5 times, you're talking about a very extended exposure. Therefore, stopping the medication doesn't necessarily change your immune response in a short period of time.

We can take this discussion a step further by considering recent data suggesting that a subgroup of patients with severe COVID-19 may experience a putative cytotoxic storm. These patients have been noted to have a hyperaccelerated inflammatory response, which occurs regardless of the level of viral load; simply having the virus present is enough to stimulate the response. This cytotoxic response results in a variety of upregulations, including white cells and migration factors, especially interferon-gamma, interleukin-2 and -6, and tumor necrosis factor alpha. Crucially, these are also targets for many of the IBD mitigation strategies we employ with our biologic and immunosuppressant therapies. It is therefore conceivable that there may even be some benefit to the medications that these patients may take.

At the moment, we can reassure our patients with IBD that they can stay the present course and continue their medications, with the obvious stipulation that they must apply the standard COVID-19 precautions.

We can also extend our kudos to this incredible international group for giving us excellent guidance, reassurance, and justification for the management of a very complex group of patients on biologics and immunosuppressive therapies. That's what leaders do in a time of crisis—they lead. Hopefully this overview of their work has provided you with good information to guide your decisions and discussions with patients.

I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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