Don’t stop anti-TNFs, ustekinumab or vedolizumab
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We’re learning more each day about coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). For patients with inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease, the current pandemic situation requires several new considerations.
Right now, we do not believe that people with IBD are at greater risk for developing COVID-19, although we have little data.
As of March 25, 2020, there were 87 reports of patients with IBD and COVID-19 in the international Surveillance Epidemiology of Coronavirus Under Research Exclusion database (SECURE-IBD). Of those, 50 had Crohn’s disease, 36 UC, and one unknown IBD. Overall 19 (21.8%) were hospitalized, 2 (2.3%) placed on ventilators and 5 (5.7%) died.
Most U.S. states have now advised that nonessential procedures, including endoscopies and gastrointestinal surgeries, be postponed until the virus is under control. This is for the safety of both the patient and provider, as well as to avoid depleting limited supplies of personal protective equipment.
As for treatments, the International Organization For the Study of Inflammatory Bowel Disease has issued guidance stating that patients should continue taking biologic medications including anti-TNFs, ustekinumab and vedolizumab.
This is advised because inflammation itself may be a risk factor for acquiring COVID-19. We prefer that our IBD patients who are doing well on these medications not stop them and raise the risk of a flare or active inflammatory changes in the GI tract. But of course, we need to caution these patients to avoid travel, practice handwashing and sheltering as much as possible.
Mesalamines are also considered safe. However, steroids such as prednisone and prednisolone are another matter. We don’t have data, but we believe high doses (over 20 mg per day) could globally impair the immune response in such a way as to be detrimental to patients should they be exposed to SARS-CoV-2. If steroids must be used — as in the setting of a flare while awaiting prior authorization for a biologic — we advise limiting the steroid dose, ideally to less than 20mg/day, and to taper them off within weeks rather than the usual one to two months.
Thiopurines (6-mercaptopurine, azathioprine) and tofacitinib also tend to inhibit the body’s immune response to viral infections. The thiopurines take weeks to months to leave the body and stopping them may not help in the short term. However, for patients who develop a severe viral infection, we recommend stopping these medications during the infection.
Of 87 IBD patients reported in SECURE-IBD, 21 (24%) had their medications stopped due to COVID-19.
Clearly, we need to learn much more to inform our care of IBD patients during this pandemic. Clinicians worldwide are encouraged to report all confirmed cases of COVID-19 in patients with IBD, regardless of severity — including asymptomatic individuals detected through screening. Reports should be made only after resolution of acute disease or death, at a minimum of seven days. Cases can be reported here.
For more on COVID-19 and IBD, check out our recent ConsultQD Live episode of IBD Live.
Dr. Regueiro is Chairman of Gastroenterology and Hepatology at Cleveland Clinic.
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