Out of more than 220,000 residents of Los Angeles County who have tested positive for SARS-CoV-2, the virus that causes COVID-19, no patients with inflammatory bowel disease (IBD) have died, according to a review of the pandemic’s impact in Southern California by Gil Melmed, MD, and Christina Ha, MD, presented at the August 22 virtual Advances in Inflammatory Bowel Disease regional meeting.

Dr Melmed is codirector of the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center in Los Angeles, California. Dr Ha is an associate professor of medicine and director of the Inflammatory Bowel Disease fellowship at Cedars-Sinai.

Dr Melmed reported that the past 3-day average, as of August 22, showed that 1500 patients had been hospitalized for COVID-19, and the 7-day average death rate was trending down, at about 30 per day. 

The SECURE-IBD Registry, which he explained had been established “to rapidly define the impact of COVID-19 on patients with IBD,” has reported 773 cases of COVID-19 in patients with IBD in the United States and 6 deaths, with 2035 cases and 64 deaths worldwide. However, he cautioned, this data is all self-reported, and “we don’t know what we don’t know.”

Dr Melmed praised SECURE-IBD as “a terrific international effort and a paradigm for other disease states” that has been replicated by other organizations.

The primary issues concerning gastroenterologists treating patients with IBD is which therapeutics may increase their patients’ risk of contracting COVID-19. Although there was initial concern that any immunosuppressant drugs might create higher risks, Dr Melmed said that so far, it appears that anti-tumor necrosis factor (TNF) therapeutics, methotrexate, tofacitinib, and azathioprine do not increase the risk of infection among patients.

However, patients using corticosteroids do appear to be at higher risk of infection and complications, Drs Melmed and Ha agreed, and they urged gastroenterologists to discontinue the use of steroids among their patients during the pandemic.

Safety guidelines for gastroenterologists and their allied health workers when performing endoscopic procedures, especially regarding the use of personal protective equipment guidelines came out early, before testing was widely available, Dr Melmed noted. “They may be different in different regions,” but in general the advice remains that all personnel conducting endoscopies should wear N95 masks and double gloves. Negative pressure is advised if the patient is known or presumed to be COVID-19 positive, and procedures should be done based on time sensitivity. If the procedure is elective, postponing may be the best course.

Dr Ha presented a case scenario that a gastroenterologist might encounter, in which a patient with IBD has been exposed to someone who has tested positive for COVID-19. “What steps should we follow and how do we advise our patients?” she asked. First, the extent of exposure must be considered. The Centers for Disease Control and Prevention (CDC) defines “close contact” as more than 15 minutes at 6 feet, or direct physical contact, with someone who has tested positive.

If the patient with IBD is asymptomatic, she advised that the patient should quarantine for 14 days, because testing after shorter periods of time can result in false negatives. “What about the IBD medications? If the patient has no symptoms or slight symptoms, the patient should continue to take their medications,” Dr Ha stated. In the case of a patient on combination therapy of a biologic and an immunomodulator, “You might want to hold the immunomodulator during the quarantine period. But definitely, we should discontinue steroids in these patients.”

An exposed but asymptomatic patient who is due for an infusion during the quarantine window presents a “tricky” situation, Dr Ha said. “You don’t want to expose a home infusion nurse or others at an infusion center. If the patient is due for an infusion during the quarantine window, you may want to get them tested. If they’re just beginning infusion, that can be a harder decision.”

Dr Melmed noted that he had a patient scheduled for colonoscopy who had been exposed to a person who tested positive for COVID-19. “We postponed the procedure until after the quarantine period,” he said.

Dr Ha agreed that these decisions must be made on a case-by-case basis. “With asymptomatic patients who have been exposed to COVID-19, if possible, delay procedures and some medications until the quarantine is over and especially, get your patients off of steroid therapy.”

In the case of patients with IBD who have active COVID-19, Dr Ha said, “They should be in self-isolation. Follow the CDC guidelines. These patients should remain isolated until 10 days after onset of symptoms; then they should be afebrile for 24 hours without use of medications such as Tylenol, and they should show a marked improvement in symptoms.”

She further noted that while “there are lots of recommendations about stopping immunomodulators, but not nearly as much advice about when and how to resume. I would resume right away, except for patients going to an infusion center.”

Neither Dr Melmed nor Dr Ha recommend testing patients for antibodies. “I’m not exactly sure what to do with that information,” Dr Ha said. “We don’t really know what positive titers mean, and it doesn’t really change any of our recommendations in regard to treatment.”

In general, patients with IBD should continue all routine medical care, including vaccinations, as long as they are stable. If a vaccine for COVID-19 becomes available, Drs Melmed and Ha would advise patients to take it. And, Dr Ha stressed, “Get the flu shot! It’s safe and effective.”

—Rebecca Mashaw

Reference:

Melmed GY, Ha, CY. Regional update on COVID-19 and IBD patients. Talk presented at: Advances in Inflammatory Bowel Disease 2020 regional meeting; August 22, 2020; virtual.