Public health

GESA: Care advice for IBD patients amid COVID-19

Associate Professor Jake Begun

GESA has made available advice for clinicians on how to manage patients with IBD during the COVID-19 pandemic.

The principles for clinicians and a patient information document represent a consensus of opinion in a rapidly evolving situation – balancing the risks of exposing patients to COVID-19 infection against the need to manage IBD and prevent flares and complications.

As well as generic advice on minimising risk of infection via personal hygiene and social distancing, including the use of telehealth consultations where appropriate, the statement for clinicians suggests patients receive “…the minimum level of immunosuppressive or biologic therapy to control disease activity”. 

“Some patients with long-term stable disease may be able to be considered for a ’drug holiday’,” it said. 

“For appropriate patients in long term stable remission, infusion intervals lengthening may be considered.”

The statement also suggested infusions should preferably be given outside hospitals or in settings that minimise exposure to SARS-CoV-2 infection.

It said there was no evidence for switching patients from IV to subcutaneous biologic agents.

As previously indicated by GESA and reported in the limbic, non-urgent endoscopy for IBD patients should be delayed in lieu of non-invasive biomarkers and imaging for surveillance and post-op assessment.

GESA IBD Faculty chair Associate Professor Jake Begun told the limbic urgent indications such as acute severe colitis, cancer concerns or symptomatic strictures would continue to be priorities.  

He said the unprecedented situation of COVID-19 meant IBD nurses were manning helplines fielding enquiries from concerned patients. 

“So it is really helpful to have something we can now send out to them. We have tried to capture the most common questions and those that would have the biggest impact for patients but of course there is a lot we didn’t include because you don’t want a document that is too long.”

He said clinicians were understandably nervous about recommendations such as drug holidays.

But it suited patients who were in long-term clinical remission with mucosal healing. 

“Those are the people where now is a good time to maybe consider that and bring that plan into effect. You just want to make sure you are selecting the right patients for that.”

“As far as the dose lengthening recommendation, that was one that was also endorsed by ECCO, and that is based on some clinical trial data that showed patients in stable remission on dosing, can often be lengthened out.”

“You have to watch them carefully but I think that the message to patients is, if we are considering these sorts of things like dose lengthening or drug holidays, it means we think you have your disease under really good control.”

He said patients would be anxious about coming into a healthcare environment for infusions like infliximab or vedolizumab.

The statement also included advice for patients who do contract COVID-19 such as holding “… therapies that may impact the ability of T- cell mediated viral clearance (thiopurines, anti-TNF agents, anti-IL23 agents, tofacitinib, and vedolizumab for patients with prominent COVID-19-related GI symptoms).” 

“Typical symptom duration is 3-5 weeks, and a pause in therapy of this duration is unlikely to precipitate a major flare.”

Associate Professor Begun said COVID-19 was yet another consideration that goes into the risk equations physicians calculate everyday with the patients’ best interests in mind.

“I do think we should be individualising our care plans for our patients based on their history, their current symptoms and status and coming up with good plans for each patient as they present.”

“In our hospital and in our private rooms, we have switched over to almost entirely telehealth. Patients have been very understanding and happy that we are taking those proactive steps.”

“I think the other thing that is going to be happening if there is going to be a pull on resources and people are going to deployed into COVID areas and so it is also a matter of trying to figure out and put in places systems where you can provide the service you need to for our patients while also providing services to our hospitals who are struggling under the strain that is coming.”

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