David Rubin, MD, on How I Practice Now

Dr Rubin provides perspective on the impact of the COVID-19 pandemic on the practice of gastroenterology and particularly what has been learned about the risks to patients with inflammatory bowel disease.

David Rubin, MD, is chief of gastroenterology, hepatology, and nutrition and codirector of the Digestive Diseases Center at UChicago Medicine.

Hi, I'm Dr. David Rubin from the University of Chicago. I'm delighted to contribute to the "How I Practice Now" Series for us to think a little about how we're addressing COVID and inflammatory bowel disease.

We've been living with the COVID pandemic now for almost eight months. We've learned quite a bit, and we've also been able to develop some new strategies for taking care of our patients.

In the beginning, of course, we didn't know whether our patients were at increased risks for having problems with the coronavirus infection. We didn't necessarily know whether the therapies they were taking would put them at increased risk or even be protective. We certainly didn't know how to use telehealth very efficiently.

We've now made a lot of progress in these areas, and I wanted to highlight them for you. The first is that, from the early days, we did hope and think that patients with inflammatory bowel disease were not at increased risks for worse outcomes from COVID.

Now all these months later, and after looking at a number of different studies including an international registry, we have in fact documented that patients who have Crohn's disease and ulcerative colitis are not at increased risk for getting infected and they're not at increased risk for having worst outcomes if they are infected with the SARS-CoV-2 virus.

That doesn't mean they're at decreased risk necessarily, either. The other thing we've learned as we've gone through all these months is that hand hygiene, social distancing, and wearing masks do work. They work well-enough not only to be recommended and certainly to protect people from getting infected. They also work well-enough to protect health care workers who are taking care of these patients.

As much as we've now been relying on video visits, we also now are able to see our patients. We're able to perform endoscopic procedures, and we can do so safely, in part because we've learned more about how to protect ourselves, how to protect our patients.

We also have now available to us more testing that enables us to get results before we perform elective procedures or even non-elective procedures. Point-of-care testing has improved in its sensitivity for picking up the virus.

We can use these tests to help us know whether a patient has an infection as part of our evaluation, but also to test them before they have a procedure so that we know we're protecting the rest of the healthcare team.

In terms of taking care of Crohn's disease and ulcerative colitis, we've learned that patients with Crohn's and colitis can have the coronavirus, and it can cause digestive symptoms. Almost always when patients have digestive symptoms from coronavirus, they will also have respiratory symptoms and fever.

In distinguishing a patient with Crohn's and colitis who's having a flare or a relapse of their disease from somebody who might have coronavirus giving them new digestive symptoms, we have to look for those other problems, like a cough, congestion, loss of taste or smell, and obviously fever, and other things like X-rays or CT scans of the chest or other lab abnormalities.

Distinguishing between a relapse of inflammatory bowel disease and someone who has coronavirus is fairly straightforward at this point. We have not seen any hard evidence to suggest that getting a coronavirus infection will trigger a relapse of inflammatory bowel disease.

There are variety of people who have said they've seen a case where they think it may have happened or where they even think that the coronavirus infection may have triggered a new onset of inflammatory bowel disease, but nothing that's enough to make us think that this is a real phenomenon as opposed to a coincidence at this time.

What we do know leads to relapses of inflammatory bowel disease is if patients stop taking their medications. We want to continue to emphasize that one of the main messages from all of our different societies that have weighed in, and supported by the evidence, is that patients should stay on their medicines that keep them in remission.

As we've moved into the era now of video visits, this has certainly been something that lends itself nicely to patients with chronic conditions. The routine visits that we've been recommending for patients with inflammatory bowel disease as part of their care to monitor their disease and to check in about their therapies are perfect for video visits.

There are also a variety of different tests that we can order with local lab assistance or having the patients come in briefly to have their blood drawn or to drop off a stool specimen so that we can keep track of their disease.

As much as we've relied on video visits and my colleagues have become very expert and efficient at them and we enjoy doing them, we also need to set some boundaries to know when it's more appropriate to see the patient in person.

I've been suggesting that, once we get to the new reality and perhaps when the pandemic is over, video visits are going to remain part of what we do. Patients should probably see their gastroenterologist for an evaluation of their inflammatory bowel disease in person at least once per year.

They should see them if they're having a significant relapse, and they definitely should let their doctor know or their healthcare team know if they're having new symptoms that warrant further evaluation.

Remember, we can't do some of the exams that we really need to do with our patients, like percuss to find out if there's tympany or distention. Certainly can't do a perianal exam by video visit, and there's a variety of things we want to keep in mind.

The other issue that is quite important is to recognize that many of our patients may not be in a private environment where they can confide in their doctor over a video visit and talk about other issues that may be important to them. If their one computer in the family's in the kitchen and there's other people on the household, we should be sensitive to that as well.

Getting to the therapies that our patients are taking, as the data have accrued, what we've really learned now is that the anti-cytokine therapies -- which include our anti-TNF therapies in IBD, includes our anti-IL-12/23 inhibitor ustekinumab in IBD, and also our small molecule JAK inhibitor tofacitinib -- all of these therapies appear to be safe and may have some benefit during the inflammatory phase of COVID.

In other words, that inflammatory phase that leads to pneumonia and worse outcomes, these therapies may be somewhat protective. In fact, in the secure IBD international registry analyses, patients on anti-TNF statistically were likely to have better outcomes. There may be something real here.

We do know of a number of prospective trials exploring whether anti-TNF, or tofacitinib, or other JAK inhibitors may be beneficial in patients who have COVID. What has also continued to appear is that being on higher doses of steroids at the time of infection may be associated with worse outcomes.

This may be related to the fact that the steroids affect the body's ability to fight the infection during the first phase of the coronavirus infection. It may also be the people who are on higher doses of steroids for their inflammatory bowel disease or other immune diseases have poor control of their other condition, so active disease may also be a confounder there that makes them do worse.

We've learned from the prospective study that was performed in the United Kingdom called RECOVERY that giving dexamethasone in patients who need supplemental oxygen or who are intubated is helpful, but that's in that specific setting. Being on high-dose steroids is not.

The main messaging in managing inflammatory bowel disease is not different than pre-pandemic. Get your patients off steroids. Get people to steroid-sparing therapies. Our consensus statements and our guidelines still suggest that in the face of this pandemic, we should be managing inflammatory bowel disease similar to what we did before, not holding back our treatments.

We're continuing to study such questions as, "What about combination therapy?" or "What have we seen with the 5-ASA therapies that in some analyses look like they may have some risk?" That doesn't make biological sense, and so we're wondering about unmeasured confounders that may be confusing the interpretation there.

The bottom line is that we should be reassuring our patients that they should take precautions as we've been recommending with masks, working from home when possible, certainly social distancing, and hand hygiene.

When the vaccines become available, it's reassuring to know that overall our patients are not at increased risk, but we need to know whether they'll be able to mount an appropriate immune response with vaccines. There'll be additional studies to look at that, but I'm confident that the vaccines will be safe in our IBD population given the way that the vaccines are being developed.

We've obviously made a lot of progress here. We've learned a bit along the way, but there's more to do. For the most part, it's a reassuring message about IBD.

I think the progress that we've made in video visits is certainly something that was a long time coming in the space of inflammatory bowel disease, but there are some important boundaries that we need to set in understanding how to use that approach properly. Thank you very much.