LAPORAN CME

Management of Patients With IBD During COVID-19 

Pembimbing :
dr. Suharno, Sp. PD

Disusun Oleh :
Delima Rochmah Nur S G4A020006
Ulya Jihan Muna G4A020040

SMF ILMU PENYAKIT DALAM

RSUD PROF. DR. MARGONO SOEKARJO
FAKULTAS KEDOKTERAN
JURUSAN PENDIDIKAN DOKTER
UNIVERSITAS JENDERAL SOEDIRMAN
PURWOKERTO
2021
 This article is a CME / ABIM MOC / CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/933428

Management of Patients With IBD During COVID-19 CME / ABIM

MOC / CE
News Author: Troy Brown, RN; CME Author: Laurie Barclay, MD

Posted: 7/13/2020
Note: This is the fortieth of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually
evolving. The content within this activity serves as a historical reference to the information that was available at the time of this
publication. We continue to add to the collection of activities on this subject as new information becomes available.

Clinical Context
Fever and respiratory symptoms are the predominant symptoms of COVID-19, but a significant proportion of patients have
changes in bowel habits or other digestive symptoms, which may reflect gastrointestinal inoculation from swallowing virus
particles and from intestinal expression of angiotensin-converting enzyme 2. Furthermore, SARS-CoV-2 is detectable in stool
long after resolution of respiratory symptoms or detection of the virus in the oropharynx.

The AGA has issued a clinical practice update on management of IBD during the COVID-19 pandemic. The goals of this
expert commentary were to review the emerging evidence and offer expert clinical recommendations, as patients with IBD
have particular concerns regarding their risk for infection and management of medical therapies. The AGA Institute Clinical
Practice Updates Committee (CPUC) and the AGA Governing Board commissioned and approved this update by Rubin and
colleagues, which was peer reviewed internally by the CPUC and externally through standard procedures of Gastroenterology.

Synopsis and Perspective

Patients with IBD who develop COVID-19 should stop taking thiopurines, methotrexate, tofacitinib, and biological therapies
during the viral illness, according to a clinical practice update from the AGA.

"While the COVID-19 pandemic is a global health emergency, patients with IBD have particular concerns for their risk for
infection and management of their medical therapies. This clinical practice update incorporates the emerging understanding of
COVID-19 and summarizes available guidance for patients with IBD and the providers who take care of them," the authors
wrote.

David T. Rubin, MD, University of Chicago Medicine Inflammatory Bowel Disease Center, and colleagues' recommendations
were published online April 10 in an expert commentary in Gastroenterology.[1]

Patients with IBD are asking whether they are at increased risk for COVID-19, Rubin told Medscape Medical News: "Because
they are often on immune-modifying therapy for their inflammatory bowel disease, they worry that they are in the population of
folks who are immune compromised.

"In fact, immune suppression is not [the] goal of our management of IBD, it is the immune regulation of an overactive immune
response. In some ways, the inflammatory reaction of COVD-19 that results in symptoms and respiratory failure are the same
thing -- an overactive immune response," he explained.
Clinical Picture May Vary for Patients With IBD and COVID-19
Drugs and biologics that are withheld during viral infection can be resumed once the patient's symptoms have resolved, when
follow-up viral testing results are negative, or when serologic testing shows the patient is in the "convalescent stage of illness,"
the authors wrote.

For persons hospitalized with severe COVID-19 and at risk of doing poorly, treatment of IBD will "likely take a back seat" to
COVID-19 treatment, but clinicians should consider the coexisting IBD when deciding on therapies for COVID-19 when
possible.

"It is of interest that clearance of [cytomegalovirus] is enhanced when IBD therapy is added to ganciclovir and that thiopurines
and cyclosporine may have anti-coronavirus properties," the authors observed.

For patients who are hospitalized for IBD and who have "milder or incidentally identified COVID-19," the emphasis should be
on acute IBD and on giving standard IBD care, according to the authors.

Patients with IBD who are known to have SARS-CoV-2 infection but who are not ill with COVID-19 should stop taking
thiopurines, methotrexate, and tofacitinib. Biological therapies should be withheld for 2 weeks, and the patient should be
monitored for COVID-19 symptoms.

Patients With IBD Who Are Not Infected Should Continue IBD Treatment
Persons with IBD who are not infected with SARS-CoV-2 should continue with their IBD therapies and with their infusion
regimen at "appropriate infusion centers," the authors wrote.

The goal for these individuals is to sustain symptomatic or clinical remission and "objectively confirmed inflammation control,"
as evidenced by "endoscopic improvement and normalized laboratory values," advised the authors.

Although some patients may be reluctant to visit infusion centers for fear of exposure to infected individuals, the authors
cautioned that it could be much riskier for a nurse to visit patients in their homes and possibly expose others in the household.

Patients with IBD are worried about having to stop their IBD medications if they get COVID-19, "because maintenance
therapies are there to keep their IBD in remission," Rubin told Medscape Medical News. "The longer a patient is off their
therapy for a chronic condition like IBD, the more likely they are to suffer from a relapse of the disease. We reassure them that
in most cases, COVID-19 lasts a few weeks and after they have improved, can restart their medications safely."

Role of Anticytokine-Based Treatments and Antivirals for COVID-19 Is Unclear

"It should be known that anti--cytokine-based treatments are being studied for COVID-19 therapy, and it is possible that we will
learn that, for example, continuing anti-[tumor necrosis factor (TNF)] therapies might reduce progression to acute respiratory
distress syndrome [(ARDS)] and multi-organ system failure," the authors explained, "[h]owever, in the absence of those data,
guidance is currently based on deciding whether to hold or to continue specific IBD therapies.

"Of additional interest are the anti-viral therapies and other anti-cytokine therapies that are being studied for COVID-19," the
authors continued. "Choosing therapies that may have secondary benefit in IBD (or at least do not induce bowel inflammation)
would be appropriate to consider."

When considering treatments for COVID-19 and whether to increase IBD treatment, clinicians and patients should weigh the
risks against the benefits.

Social Distancing Works for Patients With IBD

Evidence from the Wuhan IBD center in China[2] suggested that strict social distancing for patients with IBD works, Rubin said.

Gastroenterologists at Wuhan University instituted a number of measures to protect patients with IBD from COVID-19 nearly 3
weeks before the general shutdown in Wuhan. These included distributing educational information and instructions to patients,
updating them as needed, and recording patient information, such as infection risks and actions taken. None of the 318
patients with IBD had been diagnosed with the infection at the end of February.

Individuals with IBD should observe strict social distancing, work from home, practice careful hand hygiene, and stay away
from individuals known to be infected, Rubin and colleagues recommended.

Patients With IBD Who Experience Relapse Need Careful Evaluation

Rubin urged clinicians to "carefully evaluate their IBD patients who have a relapse both because it may be digestive symptoms
from COVID-19 instead, but also because much more likely it will be the usual causes -- other infections, loss of response to
therapy or due to patients who stopped their therapy on their own. A thoughtful clinical approach to these patients is critically
important so that our patients can be kept safe and get the treatments that they need."

He added, "We are learning more every day about COVID-19 and about new options for testing, screening, and outcomes of
our IBD patients who get infected. Patients should check with their doctors if they have concerns or questions, and both
patients and clinicians should stay tuned as more information becomes available. The IBD community of experts and care
providers are all working together."

A decision support tool[3] and quick reference chart for social sharing[4] are available for download on the AGA website, and
clinicians are asked to submit cases involving patients who have both IBD and confirmed COVID-19 to the SECURE-
IBD registry.[5]

The AGA Institute Clinical Practice Updates Committee and the AGA Governing Board commissioned and approved this
expert commentary. Rubin and Cohen reported a variety of financial relationships with pharmaceutical companies and
organizations, including AbbVie Inc.; Abgenomics; Allergan, Inc.; Boehringer Ingelheim Pharmaceuticals, Inc.; Bristol-Myers
Squibb Company; Bristol-Myers Squibb Company/Celgene Corporation; Celgene Corporation-Syneos Health ®; Dizal Pharma;
Galen-Atlantica; Genentech, Inc./Roche; Gilead Sciences, Inc.; GlaxoSmithKline; Hollister Incorporated; Ichnos Sciences Inc.;
Janssen Pharmaceuticals, Inc.; Lilly USA, LLC; MedImmune Inc.; Mesoblast; Osiris Therapeutics, Inc.; Pfizer Inc.;
Prometheus Laboratories Inc.; Receptos, Inc.; RedHill Biopharma Inc.; Reistone Biopharma; Sanofi; Schwarz Pharma Inc.;
Seres Therapeutics; Shire; Takeda Pharmaceuticals North America, Inc.; TECHLAB Inc.; UCB Pharma, Inc.; and the Crohn's
& Colitis Foundation. Cohen's spouse is on the board of directors at Aerpio Therapeutics; NantKwest; and Novus
Therapeutics, Inc. The remaining authors have disclosed no relevant financial relationships.

Highlights

 Although IBD is treated with immune-modifying therapy, patients with IBD do not appear to be at increased risk for
SARS-CoV-2 infection or for development of COVID-19.
 That said, persons with IBD should minimize their risk for infection by measures recommended for persons at
increased risk and for the general population (ie, strict social distancing, working from home, hand hygiene, and
avoiding persons known to be infected).
 Among 318 patients at the Wuhan IBD Center who followed these recommendations from the beginning of the
outbreak, none subsequently developed COVID-19.
 The goal of IBD management is immune regulation of an overactive immune response, which is similar to the
inflammatory reaction seen in COVD-19 that results in respiratory failure.
 To lower the risk for relapse and need for more intense medical therapy or hospitalization that could strain available
medical resources, patients with IBD should maintain remission, as these risks are much greater than the known risks
of existing IBD therapies.
 Patients with IBD who are not infected with SARS-CoV-2 should not discontinue their IBD therapies and should
continue infusion schedules at appropriate infusion centers so they can sustain symptomatic or clinical remission and
objectively confirmed inflammation control with endoscopic improvement and normalized laboratory testing.
 Infusion centers should follow a COVID-19 protocol including prescreening of patients for exposure or symptoms,
fever checks at the door, chairs spaced at least 6 feet apart, use of masks and gloves by providers and patients, and
sufficient deep cleaning after patient departure.
  Elective switching to injectable therapies is not recommended and was shown in a prior trial to be associated with
relapses.
 Patients should be reassured that their risk for SARS-CoV-2 exposure at an infusion center may be less than if they
receive infusion at home, as the administering nurse, if infected, could also expose other household members.
 To date, there is limited information in patients with IBD and confirmed COVID-19.
 Although it is too early for definitive conclusions, patients with severe IBD and COVID-19 were more likely to be
hospitalized for their IBD and/or COVID-19.
 Patients with IBD who have confirmed SARS-CoV-2 infection but have not developed COVID-19 should hold
thiopurines, methotrexate, and tofacitinib, and dosing of biological therapies should be delayed for 2 weeks while
monitoring for COVID-19 symptoms.
 They should also be actively moved to lower doses of prednisone (< 20 mg/d) or transition to budesonide when
feasible.
 Patients with IBD who develop COVID-19 should hold thiopurines, methotrexate, tofacitinib, and biological therapies
while they are ill and restart them after full resolution of symptoms, when follow-up viral testing is negative, or when
serologic tests show the convalescent phase of illness.
 Although maintenance therapies are needed to keep IBD in remission, and the risk for relapse increases with time off
these medications, patients can be reassured that in most cases, COVID-19 lasts a few weeks and IBD medications
can be safely resumed after resolution of COVID-19.
 Patients with IBD who appear to relapse should be carefully evaluated to rule out digestive symptoms from COVID-
19, but more likely causes are other infections, failure to respond to therapy, or discontinuing therapy.
 Patients who develop new digestive symptoms without fever or respiratory symptoms should be monitored for
progression of symptoms that might guide timing of testing for SARS-CoV-2 or trigger additional treatment
adjustments for patients with IBD.
 Clinicians treating patients with IBD who develop COVID-19 should carefully weigh the risks and benefits of
treatments for COVID-19 and escalating treatments for IBD, according to the severity of COVID-19 and of the IBD.
 The main goal of treatment for patients who are hospitalized for IBD and who have milder or incidentally identified
COVID-19 should be to give standard IBD care.
 In contrast, treatment for patients with poor prognosis who are hospitalized with severe COVID-19 should prioritize
COVID-19 over IBD while considering the latter when deciding on treatment options.
 For example, thiopurines and cyclosporine may have activity against coronavirus, and adding IBD therapy to
ganciclovir may enhance cytomegalovirus clearance.
 Anticytokine-based treatments are under investigation for possible efficacy in COVID-19, and continuing anti-TNF
therapies might theoretically help progression to ARDS and multi-organ system failure.
 While awaiting such data, however, current recommendations are limited to guidance regarding holding or continuing
specific IBD treatments.
 Cases of IBD and confirmed COVID-19 should be submitted to the SECURE-IBD registry at COVIDIBD.org.

Clinical Implications

 Patients with IBD who are not infected with SARS-CoV-2 should not discontinue their IBD therapies and should
continue infusion schedules at appropriate infusion centers, according to an AGA clinical practice update by Rubin
and colleagues.
 Patients with IBD who have confirmed SARS-CoV-2 infection but have not developed COVID-19 should hold
thiopurines, methotrexate, and tofacitinib, and dosing of biological therapies should be delayed for 2 weeks while
monitoring for COVID-19 symptoms.
 Implications for the Healthcare Team: Clinicians treating patients with IBD who develop COVID-19 should carefully
weigh the risks and benefits of treatments for COVID-19 and escalating treatments for IBD, according to the severity
of COVID-19 and of the IBD.

Earn Credit

References
 1. Rubin DT, Feuerstein JD, Wang AY, et al. AGA clinical practice update on management of inflammatory bowel
disease during the COVID-19 pandemic: expert commentary. Gastroenterology. Published online April 10, 2020.
https://www.gastrojournal.org/article/S0016-5085(20)30482-0/pdf. Accessed May 27, 2020. Editorial full text.
2. An P, Ji M, Ren H, et al. Protection of 318 inflammatory bowel disease patients from the outbreak and rapid spread of
COVID-19 infection in Wuhan, China. Preprint. Posted online February 27, 2020. https://ssrn.com/abstract=3543590.
Accessed May 27, 2020.
3. American Gastroenterological Association (AGA). Management of patients with IBD during the COVID-19 pandemic.
https://aga-cms-assets.s3.amazonaws.com/20204915614---Coronavirus%20IBD%20CPU%20digital
%20graphics_Flowchart_FINAL.pdf. Accessed May 27, 2020.
4. American Gastroenterological Association (AGA). AGA clinical practice update: Management of inflammatory bowel
disease during the COVID-19 pandemic. https://aga-cms-assets.s3.amazonaws.com/20204915925---COM20-
015%20Coronavirus%20IBD%20CPU%20digital%20graphics_Infographic_Twitter.jpg. Accessed May 27, 2020.
5. Coronavirus and IBD reporting database. COVIDIBD website. https://covidibd.org/. Last updated May 26, 2020.
Accessed May 27, 2020.
 

This article is a CME / ABIM MOC / CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/933428