The world is fighting the COVID-19 outbreak and health workers, including inflammatory bowel diseases specialists, have been challenged to address the specific clinical issues of their patients. We hereby summarize the current literature in the management of inflammatory bowel disease (IBD) patients during the COVID-19 pandemic era that support the rearrangement of our IBD unit and the clinical advice provided to our patients.
COVID-19; Inflammatory Bowel Disease; Coronavirus; Pandemic
| Highest risk | Moderate risk | Lowest risk |
|---|---|---|
| - Stay home at all times - Don't leave home to buy food, medicine or exercise - You must attend for infusions (only time you can come out) - Stay at least 2 meters (3 steps) from other people in your home whenever possible) - In case of delivery of food and medicine at your home, ask the courier to leave it outside the house - Make sure that anyone who enters your home washes their hands with soap and water for 20 seconds - Do not receive visitors, including friends and family, unless you need their help - Do not stop taking any medications without talking to your doctor |
- Avoid contact with people who are showing symptoms of COVID-19 - Avoid using public transport whenever possible - Work from home whenever possible - Avoid crowds and public spaces - Avoid meetings with friends and family - Use phone services or virtual technology to contact your doctor or other essential services |
For all group risks*
*
Recommendations given by the World Health Organization to the general population (21,22.)
: - Wash hands thoroughly with soap and water, for at least 20 seconds, frequently - Use 70% alcohol gel on your hands if soap and water are not available - Avoid touching eyes, nose and mouth - Clean objects and surfaces that you frequently touch (such as door handles and phones) with any cleaning product - Everyone should stay home to help prevent the spread of the virus - Avoid using public toilets+ + The presence of viral RNA in fecal samples has been reported, thus implicating a potential route of fecal-oral transmission (19). Leave home for very limited purposes* * Recommendations given by the World Health Organization to the general population (21,22.) * * Recommendations given by the World Health Organization to the general population (21,22.) : • Buying food and medication, • Exercise once a day, such as running, walking or cycling - alone or with a member of your family. • Donate blood or help a vulnerable person. • Travel for professional purposes, but only if strictly necessary * * Recommendations given by the World Health Organization to the general population (21,22.) * * Recommendations given by the World Health Organization to the general population (21,22.) Even when performing these activities, you should minimize the time spent away from home and ensure that you are 2 meters away from anyone. |
| Inpatient clinic |
|---|
| - Wards of main building evacuated to provide care specifically for patients with COVID-19 - Hospitalized IBD patients relocated to an isolated building, minimizing exposure to the virus |
| Outpatient clinic |
|---|
| - Most visits rescheduled - Medical staff monitored patients with active disease or flare with telephone calls - Laboratory tests strictly limited - Colonoscopy replaced with fecal calprotectin |
| Infusion center |
|---|
| - No accompanying person permitted - Rearrangement of seats allowing a distance of approximately 1.5 m in between - Surgical masks when available - Pre-admission screening protocol to assess for acute respiratory tract symptoms among IBD patients and their contacts - Selection of patients that could have their infusion postponed for 1 or 2 week to let more space available for rearrangements of seats (deep clinical and endoscopic remission |
| Adults | Children |
|---|---|
| Aminosalicylate acid derivatives (5-ASA) | |
| No evidence of increased risk of COVID-19 infection. Do not stop if infected with COVID-19. Oral dose of 5-ASA should be optimized for maximum dose +/- topical (rectal), to avoid starting immunosuppressants, if possible, in patients with UC. | No evidence of increased risk of COVID-19 infection. Should never be suspended. |
| Corticosteroids | |
|---|---|
| Safety during COVID-19 infection is unclear. Corticosteroids can be used to treat disease relapses in a low dose and short period as possible. Tapering as soon as possible. Budesonide can be used for patients with ileo-caecal CD. Budesonide MMX can be used for UC patients (not available in Brazil). | Safety during COVID-19 infection is unclear. Systemic corticosteroid does not confer clinical benefit. Corticosteroids can be used to treat disease relapses in a low dose and short period as possible. Tapering as soon as possible. |
| Immunomodulators (Thiopurines and Methotrexate)** ** Stopping this therapy will not have short-term benefits, as these agents take months to clear immunosuppressing effect. | |
|---|---|
| No evidence of increased risk of COVID-19 infection. Associated with the risk of serious viral infection (other than COVID-19). Initiation of monotherapy is not advised. Maintenance of combination therapy with biologics should be discussed individually. Consider stop: - Stable disease, especially when deep remission. - Elderly patients and/or those with significant comorbidities, in sustained remission. - Stop if signs and symptoms suggestive of COVID-19 develop. |
No evidence of increased risk of COVID-19 infection. Immunomodulators have been prescribed without changes in doses or intervals in almost all children. - SARS-CoV2 Positive and Negative (symptomatic): Recommend suspending immunosuppressive treatment during an acute febrile illness until fever subsides and the child returns to normal health. - SARS-CoV-2 Positive (asymptomatic): Decision of therapeutic changes should be individualized. |
| Anti-TNF therapy* * Patients who are going to start biological therapy, the subcutaneous route may be preferable on this occasion to avoid visits to clinics or hospitals. | |
|---|---|
| No evidence of increased risk of COVID-19 infection.Maintain dose and infusion interval. Consider initiation in monotherapy (adalimumab or certolizumab, as SQ, may be administered at home).Stop if develop signs and symptoms suggestive of COVID-19. | Only Infliximab and Adalimumab approved.¶
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Biologic plus immunomodulator in stable patients may increase risk over monotherapy but there is no specific evidence.
No evidence of increased risk of COVID-19 infection. Maintain dose and infusion interval.#
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Infusion facilities.
Switching from infliximab to adalimumab should be discouraged in stable patients. |
| Anti-IL-12/23p40 therapy (Ustekinumab)* * Patients who are going to start biological therapy, the subcutaneous route may be preferable on this occasion to avoid visits to clinics or hospitals. | |
|---|---|
| No evidence of increased risk of COVID-19 infection. Monotherapy is advised. General good safety profile. Stop if develop signs and symptoms suggestive of COVID-19. |
Not approved in children. |
| Anti-α4β7 integrin therapy (Vedolizumab) | |
|---|---|
| No evidence of increased risk of COVID-19 infection. Monotherapy is advised. General good safety profile. Stop if develop signs and symptoms suggestive of COVID-19. |
Not approved in children. |
| Janus Kinase inhibitors (tofacitinib) | |
|---|---|
| No evidence of increased risk of COVID-19 infection however, tend to inhibit the immune response to viral infections. Initiation is not advised. Maintain therapy without increasing the dose. Stop if develop signs and symptoms suggestive of COVID-19. |
Not approved in children. |
