Protecting patients with IBD during the COVID-19 pandemic
Authors: Gionata Fiorino, Laurent Peyrin-Biroulet, Silvio Danese
Journal: The Lancet. Gastroenterology & hepatology (2020)

We read with great interest the Correspondence from Ping An and colleagues1An P Ji M Ren H et al.Prevention of COVID-19 in patients with inflammatory bowel disease in Wuhan, China.Lancet Gastroenterol Hepatol. 2020; 5: 525-527Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar regarding protection measures against coronavirus disease 2019 (COVID-19) adopted for patients with inflammatory bowel disease (IBD), in Wuhan, China. The pandemic, caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is rapidly leading to saturation of intensive care units and inpatient beds. The need for full-time physicians and nurses dedicated to patients with COVID-19 is requiring fast and complex reorganisation of clinical activities in many divisions, including IBD units.2Fiorino G Allocca M Furfaro F et al.Inflammatory bowel disease care in the COVID-19 pandemic era: the Humanitas, Milan experience.J Crohns Colitis. 2020; (published online March 24.)DOI:10.1093/ecco-jcc/jjaa058Crossref Scopus (66) Google Scholar, 3Danese S Cecconi M Spinelli A Management of IBD during the COVID-19 outbreak: resetting clinical priorities.Nat Rev Gastroenterol Hepatol. 2020; (published online March 25.)DOI:10.1038/s41575-020-0294-8Crossref Scopus (98) Google Scholar IBDs are immune-mediated diseases, which usually require treatment with corticosteroids, immunomodulators, or monoclonal antibodies to induce and maintain clinical and endoscopic remission. The use of these agents can increase the risk of opportunistic infections, but not that of serious infections. Therefore, adoption of adequate measures to prevent and protect patients is an essential part of the quality standards of care in IBD. An and colleagues stopped biologics (infliximab infusions) and immunosuppressive treatments for all patients with IBD. This decision is challenging. Indeed, a systematic review4Mao EJ Hazlewood GS Kaplan GG Peyrin-Biroulet L Ananthakrishnan AN Systematic review with meta-analysis: comparative efficacy of immunosuppressants and biologics for reducing hospitalisation and surgery in Crohn's disease and ulcerative colitis.Aliment Pharmacol Ther. 2017; 45: 3-13Crossref PubMed Scopus (176) Google Scholar showed that the risk of hospital admission (odds ratio 0·48, 95% CI 0·29–0·80) and surgery (0·67, 0·46–0·97) is significantly reduced by use of biologics for patients with IBD. The probability of relapse after stopping effective immunomodulators or biological therapy is about 50% and is associated with an increased need for steroids, and risk of hospital admission and surgery.5Torres J Boyapati RK Kennedy NA Louis E Colombel JF Satsangi J Systematic review of effects of withdrawal of immunomodulators or biologic agents from patients with inflammatory bowel disease.Gastroenterology. 2015; 149: 1716-1730Summary Full Text Full Text PDF PubMed Scopus (163) Google Scholar Some considerations are needed. First, SARS-CoV-2 infection should be considered as a serious rather than an opportunistic infection, as the risk of infection is not related to concomitant immunosuppression. Second, severe COVID-19 might be associated with cytokine storm and is possibly related to a hyper-immune response in addition to virus-related damage. Third, around 5% of patients who relapse because of withdrawal of effective therapies will require hospital admission against a backdrop of overwhelmed hospital capacity. Thus, the risk and benefits of continuing or stopping biologics should be carefully balanced and should not be assumed to be a general rule for all patients with IBD, especially given the length of time the pandemic is likely to last. In conclusion, protection of patients with IBD from COVID-19 is crucial and strongly advisable. Whether stopping or adapting therapies will have substantial positive benefits for patients with IBD requires further, longer-term data from different countries. GF reports fees for acting as a speaker, consultant, or advisory board member from AbbVie, Janssen, Ferring, Celltrion, Takeda, Pfizer, Sandoz, Samsung Bioepis, MSD, Roche, Amgen, Vifor, and Mylan, outside the submitted work. LP-B reports grants and personal fees from AbbVie, Takeda, and MSD, personal fees from Janssen, Genentech, Ferring, Tillots, Pharmacosmos, Celltrion, Boerhinger Ingelheim, Pfizer, Index Pharmaceuticals, Sandoz, Celgene, Biogen, Samsung Bioepis, Alma, Sterna, Nestlé, Enterome, Allergan, Roche, Arena, Gilead, Hikma, Amgen, BMS, Vifor, Norgine, Mylan, Lilly, Fresenius Kabi, Oppilan Pharma, Sublimity Therapeutics, Applied Molecular Transport, OSE Immunotherapeutics, Enthera, and Theravance, outside the submitted work. SD reports fees for acting as a speaker, consultant, or advisory board member from AbbVie, Merck and Co, Schering Plough, UCB Pharma, Ferring, Cellerix, Millennium Takeda, Nycomed, Pharmacosmos, Actelion, Alpha Wassermann, Genentech, Grunenthal, Astra Zeneca, Novo Nordisk, Cosmo Pharmaceuticals, Vifor, and Johnson & Johnson, outside the submitted work. Prevention of COVID-19 in patients with inflammatory bowel disease in Wuhan, ChinaAs recently outlined by Ren Mao and colleagues1 in The Lancet Gastroenterology & Hepatology, patients with inflammatory bowel disease (IBD) are at increased risk of opportunistic infections. Particular attention is therefore required for these patients during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Full-Text PDF Prevention of COVID-19 in patients with IBD – Authors' replyWe thank Gionata Fiorino and colleagues and Jonathan Segal and colleagues for their comments on our Correspondence.1 Here we seek to clarify some details. The early transmission kinetics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were described2 as a basic reproductive number estimated at 2·2 (95% CI 1·4–3·9) and a doubling of cases every 7·4 days, together with a case-fatality rate of 3·67% in Wuhan, China. Lack of knowledge and community awareness of coronavirus disease 2019 (COVID-19) along with the severity of suspected cases, possible high transmission, and the peak of the Spring Festival in China during the early stages of the outbreak, made the task of minimising the risk of transmission to our patients with inflammatory bowel disease (IBD) urgent and all the more difficult. Full-Text PDF