By David T. Rubin, MD, Professor of Medicine, University of Chicago Medicine
(Posted to IBD-circle.within3.com on March 21, 2020)

Colleagues,

A question that has come up recently is how we should approach treating active IBD during the SARS-CoV-2 pandemic.

Here are my thoughts and suggestions:
A) If you have made a new diagnosis of IBD:

1. Make sure not a mimicker infection instead. Up to 50% of patients with COVID-19 will present with GI symptoms, most especially diarrhea (see Am J Gastroenterol in press article). There are some reports of an inflammatory appearance of the small bowel, although not much more yet. SARS-CoV-2 is detectable in stool, but it is orders of magnitude less than what is in the nasopharynx. Obviously if COVID-19 is confirmed or suspected, do not start IBD therapies- may require waiting 7-14 days to clarify the course.
2. For mildly active disease, 5-ASA (UC), budesonide (CD and UC), and partial or full enteral nutrition (small bowel CD, mostly pediatric) are completely reasonable.
3. For moderately to severely active disease, it is not clear which therapies should be used now in this setting, but in general avoiding steroids is recommended (even for induction). Starting biological therapies in this setting if COVID-19 has been ruled out is appropriate. Since thiopurines and methotrexate require steroid induction and tofacitinib in the U.S. is positioned after anti-TNF therapies, these drugs would not be used during the acute phase of induction in a newly diagnosed patient.

B) If this is relapsing IBD:

1. Why is it happening? (did they stop their meds or did you stop their meds? stress? co-infection? mechanistic escape? immunogenicity?)
2. Start by ruling out infection as you always do. The usual ones of course, Clostridioides difficile and general GI infections, but keep in mind that this COULD be COVID-19 presentation too. If so, then obviously supportive care for the viral infection is indicated instead of changing the IBD therapies. Holding the IBD therapy for 2 weeks seems prudent, but probably doesn’t do much given the half-lives of most of our therapies. Even the small molecule tofacitinib has a longer in-tissue half-life.
3. Is this a “typical” flare of the IBD for THIS patient? Remember that for most patients, their IBD will be consistent in the way that it manifests a flare. If it’s a different presentation, be extra careful to consider what might be going on.
4. Use non-invasive methods to objectively assess the disease activity. Since we are currently recommending to avoid non-essential endoscopic procedures, this should include CRP (if the patient makes CRP), fecal calprotectin (but remember that we don’t know for sure yet if SARS-CoV-2 can be transmitted by stool), and possibly the MONITR test for Crohn’s disease (Prometheus Labs, San Diego), as well as usual lab testing (CBC).
5. Where is the drug? In other words, is this flare happening because the drug is gone (increased clearance, discontinuation, non-adherence) or is the drug present (and dose is still too low or there is mechanistic escape). This requires assessment of serum concentrations of the drug and the presence or absence of neutralizing anti-drug antibodies.
6. Address non-adherence, adjust the dose of current med, cycle within class (anti-TNF) or swap to different classes as you would do normally.
   – Limit your use of steroids to short duration
   – We do not have specific therapy preferences in the current pandemic. While it seems possible that ustekinumab or vedolizumab would be safe options, their role in patients who have a risk of near-term infection with SARS-CoV-2 is not clear nor are they necessarily safer than anti-TNF in this setting. Of even less clarity is whether tofacitinib can be used safely in this setting, although we think so based on very limited information so far.
7. If SURGERY is needed, adhere to your local institutional guidance if there is any, but here are some questions to consider:
   – Can it wait until after the pandemic has slowed down?
   – Should the patient be tested for SARS-CoV-2 before surgery is done? (this may vary by practice and center)

Thoughts and comments are welcome.
Best wishes,
David

David T. Rubin, MD
Professor of Medicine, University of Chicago Medicine