Corey Siegel, MD, on the IOIBD RAND Analysis of COVID-19 in IBD

In this video, Dr Siegel reviews his presentation at the Advances in Inflammatory Bowel Diseases 2020 virtual meeting on the IOIBD RAND Analysis and updates into the impact of COVID-19 on patients with IBD. 

Corey Siegel, MD, is director of the Inflammatory Bowel DIsease Center at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.

TRANSCRIPT

Hi, I'm Corey Siegel from the Dartmouth-Hitchcock Medical Center. Thank you for listening to this summary of a presentation from AIBD about the IOIBD RAND analysis and updates about COVID-19.

This was work that was done by a global group of international specialists in inflammatory bowel disease early on in the COVID-19 pandemic and really trying to understand how we should be managing our patients with inflammatory bowel disease, specifically related to their IBD-related medications.

Although we've learned a lot in the past 10 or 11 months, we had to make some decisions very early and give recommendations to the best of our ability of what we should be doing with our medications, many of which are immune-suppressing medications that clearly could have increased the risk of developing COVID-19 and getting very sick from COVID-19.

This was published very rapidly. David Rubin was the first author. With my colleagues Maria Abreu, Victoria Rai, and myself, worked with the entire IOIBD community and other specialists from around the world, who all pitched in together to think through what recommendations we can come up with.

We did put some methodology around this and did it as something called a RAND appropriateness panel, which is essentially an expert consensus panel where we're all trying to use the data that are available and make the recommendations in the face of uncertainty.

We voted on each statement, meaning each medication in different scenarios of either preventing getting COVID-19 or what to do if you develop COVID-19. Then we did some further work of if you did stop your medications because of COVID-19 for IBD, when and how can you restart them safely?

The overall messages are that most of our medications, thankfully, appear to be safe to be during this pandemic. We rarely have to stop them unless somebody's getting really sick with COVID-19.

We do have some supplemental data beyond the work that we did to check our work and see how close we were back in March and April, when we made these initial recommendations. Overall, we felt that other than prednisone at a dose of 20 milligrams or higher, none of the other medications should be stopped if you're worried about getting COVID-19 and getting sick from COVID-19.

There was some uncertainty around some of the immune suppressant medications, specifically if you are sick with COVID-19 should you stop immune suppressant medications?

Although we have had a little further data since then, at the time we thought that if in fact you are sick with symptoms of COVID-19, you should probably stop thiopurines, methotrexate, or anti-TNF therapy, in addition to probably ustekinumab and tofacitinib.

Since then we've had much more reassuring information from a worldwide database that helps us recognize that most of these drugs, other than prednisone, probably are safe. Although I'd still be cautious if patients developed COVID-19 and probably hold a dose to see which direction they're going in and hoping that they're not getting very sick, overall, these drugs are going to be on board for a number of weeks because they have such a long half-life.

The ones that I absolutely stop are high doses of prednisone, if able, and tofacitinib. I'm not convinced as much about the safety of that medication. The anti-TNF drugs and other biologic drugs, again, I don't purposely give a dose if somebody has COVID-19. I hold it until they start getting better.

With that said, there are some clinical trials going on now and some evidence that anti-TNFs might be effective in treating COVID-19. That gives me some further reassurance of the safety. Still, I don't know that I'm purposely going to give a dose to help treat their COVID-19 at this point.

Again, trying to get patients off of high doses of steroids, withholding tofacitinib—the others are a little bit dependent on how sick that individual patient is with COVID-19 or their IBD.

The next question, then, is if you held their medication and they're sick with COVID-19, when is it safe to resume therapy? Working with some infectious disease experts from around the world, we came with some recommendations that the minimum would be about 10 days—10 days because we want to see what direction patients are going in. We want to start having them clear virus.

Once they're improving in their symptoms, after 3 days and at least 10 days have passed since symptoms first appeared, it would be safe to restart any of these medications. Some places are requiring a test-based strategy, making sure that you have negative swabs before you restart therapy. Those were not our recommendations. We recommended basing this on a non-test-based strategy, or otherwise set a time-based strategy that as long as 3 days have passed since recovery, defined as resolution of fever without the use of fever-reducing medications, and improvement of the respiratory symptoms and it's been a minimum of 10 days, then it's probably safe to restart any of these medications.

It's somewhat dependent on how sick they were from COVID-19 and how serious their IBD is. If they've been in remission for years of their IBD, it's probably safe to wait a little bit longer. We even said up to a month in some cases if they had severe COVID.

However, if they had a very mild case of COVID and their IBD is quite serious and we know that missing medications leads to flares, then that 10 days is the minimum that we should be waiting.

There's a lot further information on this in publications that went in JCC, or the Journal of Crohn's and Colitis, where the IOIBD put out a supplement on all different recommendations about COVID-19 and IBD.

Thank you for listening to the summary if you weren't able to watch the entire talk. I'm sorry that we have to do this virtually, but look forward to next year where we all hope to be together in person at AIBD in 2021. Thank you.