Prevention, Diagnosis and Management of COVID-19 in the IBD Patient

Abbreviations: HR, hazard ratio; LRTI, lower respiratory tract infection; OR, odds ratio; RA, rheumatoid arthritis; CI, confidence interval; RR, relative risk; URTI, upper respiratory tract infection.

^aLow numbers, n = 9 with missing data.¹²⁶

Authors and Disclosures

Aysha H. Al-Ani¹, Ralley E. Prentice¹, Clarissa A. Rentsch¹, Doug Johnson², Zaid Ardalan¹, Neel Heerasing¹, Mayur Garg¹, Sian Campbell², Joe Sasadeusz², Finlay A. Macrae¹, Siew C. Ng³, David T. Rubin⁴ and Britt Christensen<sup>1

1</sup>Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Vic., Australia
²Victorian Infectious Diseases Unit, The Royal Melbourne Hospital, Melbourne, Vic., Australia
³Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
⁴Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA

Correspondence
Britt Christensen, The Royal Melbourne Hospital, Gastroenterology Department, 300 Grattan St, Parkville, Vic., Australia. Email: britt.christensen@mh.org.au

Aysha H. Al-Ani and Ralley E. Prentice should be considered joint first authors.

Author contributions
Aysha H. Al-Ani, Ralley E. Prentice and Clarissa A. Rentsch reviewed the literature, provided the analysis and drafted the manuscript. Doug Johnson helped to develop the concept of paper, provided ID advice on COVID and its risk and reviewed the manuscript. Zaid Ardalan, Neel Heerasing, Mayur Garg and Finlay A. Macrae contributed to the writing and revision of the manuscript. Sian Campbell and Joe Sasadeusz were involved in the literature review, drafting of COVID medical therapies section and revision of manuscript. Siew C. Ng and David T. Rubin helped to develop the concept and revision of manuscript. Britt Christensen designed the study, led the analysis and interpretation of data, and coordinated the writing and revision of manuscript.
All the authors approved the final version of the manuscript.

Declaration of personal interests
Aysha H. Al-Ani, Ralley E. Prentice, Zaid Ardalan, Neel Heerasing, Sian Cambell: None. Clarissa A. Rentsch and Doug Johnson have served as speakers for Pfizer. Mayur Garg has served on the advisory board of Pfizer and Pharmacosmos and has received speaker fees, research or travel grants from Abbvie, Janssen, Pfizer, Pharmacosmos, Shire, Takeda and Vifor. Joe Sasadeusz has received research funding from Gilead. Finlay A. Macrae has served as an advisory board member for Rhythm BioSciences, Endogene, Glutagen, and has received research funding from Rhythm Biosciences for clinical trial support in biomarkers of colorectal cancer research. Finlay A. Macrae owns stocks and shares in a superannuation portfolio with to his knowledge no relationship with the current paper. Siew C. Ng has received search grants from Ferring and Abbvie and speakers honorarium from Janssen, Abbvie, Tillotts, Takeda, Olympus and Ferring. David T. Rubin reports grants and personal fees from Abbvie, personal fees from Abgenomics, personal fees from Allergan Inc, personal fees from Boehringer Ingelheim Ltd, personal fees from Bristol-Myers Squibb, personal fees from Celgene Corp/Syneos, personal fees from Check-cap, personal fees from Dizal Pharmaceuticals, personal fees from GalenPharma/Atlantica, grants and personal fees from Genentech/Roche, personal fees from Gilead Sciences, personal fees from Ichnos Sciences, personal fees from GlaxoSmithKline Group, grants and personal fees from Janssen Pharmaceuticals, personal fees from Lilly, personal fees from Narrow River Mgmt, personal fees from Pfizer, grants and personal fees from Prometheus Laboratories, personal fees from Reistone, grants and personal fees from Shire, grants and personal fees from Takeda, personal fees from Techlab, Inc, outside the submitted work. Britt Christensen has received speaking fees from Abbvie, Jannsen, Pfizer, Takeda and Ferring, research grants from Janssen and Ferring Pharmaceuticals and served on the advisory board of Gilead and Novartis.

Sidebar 1

Sulfasalazine and 5-ASA

• Treatment with 5-ASA therapy should continue without concern for increased risk of contracting or developing severe COVID-19.

• If a patient is in contact with someone who has COVID-19 or develops COVID-19, treatment with 5-ASA should continue.

Sidebar 2

Corticosteroids

• Corticosteroids (particularly ≥20 mg prednisolone or its equivalent) are associated with an increased risk of infection; however, it is unclear if treatment with corticosteroids is associated with an increased risk of COVID-19 infection or complications.

• Where possible, corticosteroid use should be avoided and rapid tapering should be considered ± switch to budesonide. This must be weighed up against the risk of IBD flare.

• If a patient requires a course of corticosteroids to treat a flare, consider the use of budesonide or beclomethasone where possible, and in CD, consider exclusive enteral nutrition (EEN) as an alternative induction agent.

• If a patient is in contact with a person with COVID-19 or develops COVID-19, taper corticosteroids ± switch to budesonide or beclomethasone where possible, but consider need for stress-dose steroids if septic or shocked.

Sidebar 3

Immunomodulators

• No clear evidence of increased risk of lower respiratory tract infections with immunomodulators

• Some evidence that thiopurines impair viral immunity and mixed evidence that that they have some anti-viral activity.

• Weigh risks and benefits, but most patients can continue on stable dose. In older patients, those in sustained remission and with co-morbidities, consider ceasing.

• Avoid commencing thiopurines or increasing dose: this will allow patients to avoid potential side effects and frequent pathology monitoring.

• If a patient is in contact with someone with COVID-19 consider temporarily withholding thiopurines for 2 weeks.

• If a patient tests positive for SARS-CoV-2 and/or develops COVID-19, consider temporarily withholding thiopurines until patient clears infection.

Sidebar 4

Biological Therapies

• Biological therapies appear relatively safe.

• If commencing on a new patient, where appropriate consider subcutaneous dosing mechanism to reduce infusion centre burden/health facility contact.

• Elective switching from infliximab infusions to subcutaneous anti-TNF formulations is not advised as this may increase the risk of relapse.^[88]

• If on combination therapy and patient is in deep remission and/or older, consider withholding/ceasing immunomodulator therapy to reduce infection risk. If possible utilise therapeutic drug monitoring to guide decision.

• If patient is in contact with someone who has COVID-19, consider withholding anti-TNF therapies for 2 weeks. Likely safe to continue other biologics.

• If patient tests positive for SARS-CoV-2 and/or develops COVID-19, consider withholding biologics until patient clears infection.

Sidebar 5

JAK Inhibitors

• JAK inhibitors may impair viral immunity.

• Use lowest effective dose to maintain remission: Where possible maintain patients on 5 mg twice daily as opposed to 10 mg twice daily.

• Avoid commencing tofacitinib during pandemic unless there are no other alternatives. This will allow patients to avoid potential side effects and frequent pathology monitoring.

• If a patient is in contact with someone with COVID-19, consider temporarily withholding tofacitinib for 2 weeks.

• If a patient tests positive for SARS-CoV-2 and/or develops COVID-19, consider withholding tofacitinib until patient clears the infection.