COVID -19 and IBD from Nat Clinical Programme in Gastroenterology & Hepatology

From the National Clinical Programme in Gastroenterology and Hepatology

24 March 2020

COVID-19 and IBD in Ireland

Is IBD a risk factor for acquiring SARS-CoV-2 infection?
To date, worldwide 41 IBD patients who acquired SARS-CoV-2 infection have been reported to the Secure-IBD registry (covidibd.org). This includes 1 patient from Ireland. Even allowing for under-reporting, these numbers are small and suggest that IBD is not a risk factor for SARS-CoV-2 infection. We encourage any IBD patient who tests positive for COVID-19 be registered in Secure-IBD.
Do IBD patients get a severe form of COVID-19?
Of the 41 patients in the Secure-IBD registry, 10 have been hospitalized, none required ICU admission but 2 have died. These numbers are too small to draw any conclusions.
What measures should IBD patients take to avoid SARS-CoV-2 infection?
All IBD patients should observe the standard HSE and Government advice to minimize the risk of infection. Those IBD patients over 70 years of age, with significant co-morbidities or with active disease on two or more drugs including immunosuppressants, biologics and corticosteroids should stay at home except to receive healthcare.
What symptoms and signs does COVID-19 cause in IBD patients?
According to limited data, IBD patients present similarly to non-IBD patients with fever, dry cough, myalgia and the other usual clinical features of the disease. Chinese data indicate about 4% of COVID-19 patients reported diarrhoea, abdominal cramping or vomiting. SARS-CoV-2 particles have been isolated from stool. Therefore, one should keep an open mind about symptoms that might mimic an IBD flare, and arrange viral swab for any IBD patient with a fever. Consider holding immunosuppressants, biologics and corticosteroids while awaiting swab results.
Should IBD patients stop or reduce any of their medications to minimize risk of SARS-CoV-2 infection?
There is no evidence that any IBD medication increases the risk of contracting SARS-CoV-2 infection. Conversely, an IBD flare that resulted in significant morbidity might lead to worse outcome of COVID-19. Therefore, current recommendations are that IBD patients should continue treatments except corticosteroids. Most clinical trials in IBD have paused recruitment but patients already enrolled should continue.
When an IBD patient develops COVID-19, how should they be treated?
Current recommendations are to individualize all treatment decisions in such IBD patients with COVID-19 in conjunction with infectious disease specialists. This likely to include holding of immunosuppressants and biological IBD treatments, but there is very little evidence to guide any such clinical decisions.
Can IBD patients undergo endoscopy or scans during this SARS-CoV-2 outbreak?
Elective non-urgent procedures are cancelled in most hospitals around the world. The reasons for this include social distancing, permitting reallocation of staff to COVID-19 care areas, and preservation of PPE. However, in case of severe IBD flares or any other urgent clinical situation,
clinicians should use judgement to decide when to perform endoscopy or scans in IBD patients and
consider using non-invasive measures such as calprotectin instead.
How can IV treatment units adapt to minimize the risk of SARS-CoV-2 transmission?
IV units should continue to treat all patients. According to HSE guidelines, all patients should be
screened for COVID-19 symptoms before attendance at the unit. Any patient who reports possible
COVID-19 symptoms should be referred for testing and IV treatment delayed until negative swab
results. Standard infection control precautions must be maintained. Patients must be scheduled in
such a way that a minimum of 2m social distancing can be maintained. If the capacity of the unit is
insufficient, stable patients could have infusions deferred for up to 2 weeks.
Are subcutaneous biologics preferred to intravenous in order to minimize hospital visits for IBD
Switching from IV to SC biologics is an option but flares could occur. When starting a biologic, an SC
option may be preferable to minimize hospital visits.
How should outpatients clinics be run?
Routine IBD patient follow up should be by virtual clinics using telephone or videoconferencing. Only
new patients and those in significant flares should be seen face to face.
Should IBD patients who are healthcare workers observe additional precautions?
Occupational health will provide individualized guidance but those IBD patients who are on
immunosuppressants or biological drugs should avoid duties that involve COVID-19 patient contact.

Prof LJ Egan
IBD Sub-group lead

Prof C Ó Moráin
National Clinical Lead