COVID-19 guidance released for managing IBD patients, endoscopic procedures

The American Gastroenterological Association (AGA) released guidance this month on medication management for patients with inflammatory bowel disease (IBD) during COVID-19, as well as for personnel performing endoscopic procedures.

Patients with IBD and no symptoms of COVID-19 should continue IBD therapies, including scheduled infusions, the AGA said in a clinical practice update. IBD does not seem to increase risk for infection with the novel coronavirus or for COVID-19. Patients with IBD who develop symptoms of COVID-19, such as fever or respiratory or digestive symptoms, should stop taking thiopurines, methotrexate, and tofacitinib, as well as biological therapies, including anti-tumor necrosis factor agents, ustekinumab, and vedolizumab, the AGA said.

No medications should be stopped without consultation with a physician, and treatment can be restarted after COVID-19 symptoms have completely resolved, the AGA said. The AGA also advised physicians to submit cases of IBD and confirmed COVID-19 to the SECURE-IBD registry. The clinical practice update was published as an expert commentary on April 10 by Gastroenterology.

On April 1, the AGA released rapid recommendations on performing endoscopic procedures during the COVID-19 pandemic, including guidance on use and potential reuse of N95 versus surgical masks and use of double gloves versus single gloves. When any GI procedure is performed in patients with known or presumptive COVID-19, the AGA suggested the use of negative pressure rooms over regular endoscopy rooms, when available. The clinical practice guideline also included best practices on use of personal protective equipment and guidance on triaging GI procedures.

In other COVID-19 news, two reports from China looked at digestive symptoms in patients with confirmed cases of the disease. The first, published by the American Journal of Gastroenterology on April 14, was a cross-sectional study involving 204 patients presenting to three hospitals in China from Jan. 18 to Feb. 28. All patients had COVID-19 as confirmed by real-time polymerase chain reaction and had complete laboratory, imaging, and historical data available. Most patients presented to the hospital with fever or respiratory symptoms, but 38 cases (18.6%) reported a GI-specific digestive symptom, such as diarrhea, vomiting, or abdominal pain. Six patients had digestive symptoms but no respiratory symptoms.

Patients with digestive symptoms had a longer time from symptom onset to hospital admission than patients without (9.0 d vs. 7.3 d, respectively), as well as higher mean levels of liver enzymes, lower monocyte count, and longer prothrombin time. Patients with digestive symptoms were also more likely to receive antimicrobial treatment, the authors found. They concluded that digestive symptoms are common in COVID-19 and that there may need to be a higher index of suspicion for the disease in at-risk patients who present with such symptoms.

The second report, which focused on GI symptoms and mild disease, was published in the same journal on April 15. Patients with mild cases of COVID-19 and at least one digestive symptom (e.g., diarrhea, nausea, and vomiting), with or without respiratory symptoms, were compared with patients who presented with respiratory symptoms alone. Of the 206 patients in the study, 48 presented only with digestive symptoms, 69 presented with both digestive and respiratory symptoms, and 89 presented with respiratory symptoms alone.

Among the 117 patients who presented with digestive symptoms, 67 had diarrhea, 13 (19.4%) as their first symptom. Overall, 62.4% of patients with a digestive symptom were found to also have a fever. Patients with digestive symptoms tended to present for care later than patients with respiratory symptoms (16.0 d vs. 11.6 d; P<0.001) but took longer to clear the virus after symptom onset and were more likely to have a fecal sample that tested positive (73.3% vs. 14.3%; P=0.033).

“These data emphasize that patients with new-onset diarrhea after a possible COVID-19 contact should be suspected for the illness, even in the absence of cough, shortness of breath, sore throat, or even fever. These patients should self-quarantine and seek medical care if not already under evaluation,” the authors wrote. They concluded that “Failure to recognize these patients early may often lead to unwitting spread of the disease among outpatients with mild illness who remain undiagnosed and unaware of their potential to infect others.”