The GESA IBD faculty has provided a more comprehensive guide to the management of patients with IBD in the context of the COVID‐19 pandemic in the Australasian setting.
The review, published in Internal Medicine Journal, updates early advice from GESA on the principles of caring for patients with IBD.
It confirms that patients with IBD do not appear to be at increased risk of SARS‐CoV‐2 infection compared to the general population but exposure should nevertheless be minimised.
As well as personal hygiene practices and social distancing, it recommended telehealth for routine appointments, access to infusion centres away from hospitals, optimisation of nutrition, a reduction in IBD activity, smoking cessation and vaccination to reduce co-infections.
“Overall, medications should not be ceased without careful consideration of risk of disease flare, and corticosteroids should be avoided or exposure minimised,” GESA advises.
Importantly, anti‐TNFs are considered safe to continue during the pandemic. In older patients in deep remission with good biologic levels, a drug‐holiday from immunomodulators in combination therapy could be considered.
Most other biologics are also considered safe to either start or continue during COVID-19, (see below).
The review also made non-evidence based recommendations regarding the temporary withholding of biologics in patients either exposed to COVID-19, testing positive to the virus or developing the disease.
“In those who develop COVID‐19, testing for clearance of virus before recommencing medications or accessing infusion centres may have limited utility as some patients shed virus for extended periods of time despite not being actively infected or infectious,” the authors said.
“Relying on testing to clear these patients may result in unnecessary delays to IBD treatment.”
They warned that inappropriate cessation of medications poses risks to patients with IBD which could be further compounded by a potential lack of access to healthcare.
“Maintaining quality IBD care is imperative. Engagement with IBD Services can be facilitated through IBD Helplines, telemedicine clinics, as well as dissemination of accurate information via a regular IBD newsletter.”
They noted that nutritional interventions may be required in patients with COVID-19 who were unable to maintain adequate oral nutritional intake due to a need for prolonged intubation or non‐invasive respiratory support.
“Enteral feeding via nasogastric tube (NGT) remains the preferred first line option, and should be considered within 24 h of admission for those requiring intensive care support.”
Medication management during pandemic:
Corticosteroids: Avoid where possible. Wean rapidly but instruct patient not to abruptly cease. Instruct patients not to self-administer. If corticosteroid or induction agent required consider switch to budesonide or exclusive enteral nutrition in CD or budesonide MMX system in UC.
Budesonide: Safe to start. Continue if required. Use in preference to systemic corticosteroids where possible.
Immunomodulatory: Avoid commencing or altering dose unless required, to prevent side-effects and reduce pathology monitoring.
Thiopurines (azathioprine, mercaptopurine): Continue in most patients
Methotrexate: If on combination with biologic therapy, in deep remission, with good anti-TNF levels on TDM and particularly if >65 years: consider drug holiday for immunomodulator.
Anti-TNF (infliximab, adalimumab, golimumab): Continue Subcutaneous route preferential if commencing new agent to avoid healthcare contact. Avoid elective switching to subcutaneous infusions due to risk of flare If on combination with biologic therapy, in deep remission, with good anti-TNF levels on TDM and particularly if >65 years: consider drug holiday for immunomodulator.
Anti-Integrin (vedolizumab): Safe to start. Continue therapy.
Ustekinumab: Safe to start. Continue therapy.
JAK inhibitors: Avoid commencing due to side-effects and need for frequent pathology monitoring. Continue if currently on tofacitinib with lower maintenance dose of 5 mg BD where possible.