key: cord-013370-gktnz644 authors: Abreu, Maria T; Peyrin-Biroulet, Laurent title: Providing Guidance During a Global Viral Pandemic for the Care of Patients With Inflammatory Bowel Disease date: 2020-10-21 journal: J Crohns Colitis DOI: 10.1093/ecco-jcc/jjaa116 sha: doc_id: 13370 cord_uid: gktnz644 nan The COVID-19 pandemic has taken both physicians and patients by surprise. Never in the history of man have we witnessed such a rapid spread of a virus, which highlights the vulnerability and interconnectivity of the world. The International Organization for the Study of Inflammatory Bowel Disease [IOIBD] is a society composed of IBD specialists from around the world. The members are gastroenterologists, both adult and paediatric, colorectal surgeons, and gastrointestinal pathologists. Members are chosen on the strength of their contributions to the field of inflammatory bowel disease and because of their regional reputation as the leaders in IBD of their region. We have partnered closely with the European Crohn's and Colitis Organisation because of our shared desire to provide the best guidance to patients with inflammatory bowel disease at a global level, as well as to the physicians that are caring for these patients. We have tried to remain cognisant of the fact that the majority of IBD patients are being cared for by general gastroenterologists who are all doing their best during this epidemic to keep their patients, staff, and themselves safe from infection. Early on when this epidemic began, we chose to put our minds together and use what information we had at the time to develop guidance for patients. The process is called a RAND panel wherein the members of IOIBD, as well as other very knowledgeable practitioners of IBD, voted on a series of statements largely having to do with the risk of infection with the SARS-CoV-2 virus and the development of COVID-19 in patients who have IBD. 1 In particular, patients who are taking immunomodulators and biologic drugs are understandably concerned about the risk of contracting SARS-CoV-2 and developing more severe COVID-19. Our first article in this online issue of JCC, dedicated to COVID-19 and IBD, shares the information from that RAND panel and goes further to describe how we resume medications, especially once patients who do have COVID-19 or have presumed COVID-19 have cleared the infection. It goes without saying that this is a moving target and, as we become more sophisticated in our ability to test accurately for COVID-19 and/or to test accurately for resolution of the infection with antibody testing, we will again see changes in how we manage these IBD patients. We urge you to continue to check the IOIBD or the ECCO websites for the most up-to-date information, and we hope to keep updating the guidance in all of the various dimensions of IBD care. ECCO has also developed guidance that is practical and described the do's and don't's of IBD care during this pandemic. Like the IOIBD guidance, it is an attempt to combine the available data with high-level IBD clinical experience. In many countries around the world, but particularly in Northern Italy and in New York where the pandemic has hit the hardest, there were many patients who required hospitalisation and who had IBD. Patients with IBD may be hospitalised either because of a flare of their disease or because they have contracted COVID-19. One of the articles in this issue deals with guidance having to do with the hospitalised patients with IBD and how best to manage them. This article also has important information having to do with surgery for IBD and the timing of surgery for IBD. It provides a very nice structure for thinking about how these patients must be managed and what to be on the lookout for, including testing for COVID, since between 5% and 18% of patients with COVID-19 present with diarrhoea which may be confused with a flare of their IBD. 2 For all intents and purposes, in many hospitals COVID testing is occurring when the patient is in the emergency room. Pregnant patients with IBD represent a special population because of the risks posed by active IBD on the developing fetus and the concerns surrounding medications' effects on the developing infant. In the era of COVID-19, pregnant women with IBD are particularly stressed about the potential for infection. Dr De Lima-Karagiannis and colleagues from ECCO have developed a very thorough document that describes what is known about pregnancy outcomes in relationship to COVID-19 and the few cases of pregnant IBD patients with COVID-19. In their thoughtful guidance document, they present data that shows pregnancy outcomes are worse in patients that develop COVID-19, with higher rates of prematurity and spontaneous abortions. They acknowledge that there is likely to be reporting bias. In high-risk areas, a high rate of COVID-19 positivity has been seen in pregnant patients who present to the hospital-thus making the case for universal testing in all pregnant women at the time of hospitalisation, although most will be asymptomatic from a COVID-19 perspective. The article also provides useful information with respect to medications in the face of pregnancy with or with COVID-19 infection. One of the sea changes that has occurred in the way we care for patients is the dialing on of telemedicine as a way to see our patients with IBD. This has been a giant step forward because for many of our patients with IBD, especially those who are on maintenance therapies and doing well, these televisits are a very compelling way to stay on top of what is happening with the patients. There are obviously nuances with respect to how different countries deal with this, especially as it relates to insurance and payers. We have done worldwide surveys of gastroenterologists with respect to how much telemedicine they were doing before and then after this pandemic, and the results are striking. We will never go back to the way things were and we will have telemedicine to stay. As time goes on, we will find new and improved ways to make this a very effective and efficient way to follow our patients. Very early on, most of our patients wanted to know if it was safe to continue on their medications and was it safe to come into infusion centres. Obviously, many of our patients with IBD are receiving intravenous medications including infliximab, vedolizumab, and the first infusion of ustekinumab. In many places, patients are also receiving these infusions at home. By the time you see this article, most home infusion centres and certainly all hospital-based infusion centres have developed protocols to keep patients and staff safe from getting COVID-19 using the proper personal protective equipment [PPE] . We have an article devoted to infusion centre guidance and, again, this will continue to evolve as it becomes easier to test patients and see if they are positive. One can imagine if we had a very rapid accurate test, we could be performing this on patients who have not yet converted just before they are to receive an infusion. At the time we write this, this is not the case. As gastroenterologists, endoscopy is a very important part of what we do. In particular in patients with IBD, it has been the mainstay of documenting mucosal healing, not to mention looking for dysplasia in patients with chronic colitis. Endoscopy runs the risk of aerosolising COVID-19 in patients who are positive. Although that risk is probably higher when doing upper endoscopies because of the airway, COVID-19 has been found in stool and is known to be able to infect the lining epithelial cells. 3 We have recently published a study looking at the expression of the two receptors that are required for viral entry and found that, in IBD patients and in healthy people, these receptors called ACE2 and TMPRSS2 are both expressed in the gut. 4 The ileum has the highest expression of ACE2 and the colon has the highest expression of the TMPRSS2. We did not see an increase in expression in IBD patients. If anything, inflammation lowers the expression of ACE2. We saw a slight protective effect or lower levels in patients who were on infliximab. Although these studies were all done from tissue collected previously and not from patients infected with COVID-19, they provide reassurance that patients with IBD are not at a greater risk of either shedding it from their stool or of contracting it through a faecal-oral route. Our colleagues provide guidance as to how best to organise an endoscopy unit and who to prioritise within the IBD space for doing procedures. For those of us who perform clinical trials in IBD, most of the pharmaceutical companies transiently put on hold enrolling new patients into the study and are dealing with what to do with patients who are already in the study, especially those that require in-person visits or colonoscopies, stool collection, or blood collection as part of the study. We provide a general overview of how the Food and Drug Administration and the European Medicines Agency have dealt with this crisis and how best to continue clinical trials and to be ready, when things get better, to start up again with clinical trials. And finally, this pandemic in many ways has given us an opportunity to think and analyse what we have been doing. It has energised all of us to think about how this can be a platform for investigation. The manuscripts provide many important, unanswered questions that as a community of physicians caring for IBD patients we should work together to address. We hope that you will find the information in this issue helpful. Please stay tuned and continue to visit our websites at [ioibd.org] or [ecco-ibd.eu] for the latest information on all these topics. We have also provided on the websites downloadable content, in particular infusion centre, endoscopy, and telemedicine guidelines that can be printed and posted in your centres. Management of patients with Crohn's disease and ulcerative colitis during the COVID-19 pandemic: results of an international meeting Gastrointestinal and hepatic manifestations of 2019 novel Coronavirus disease in a large cohort of infected patients from New York: clinical implications SARS-CoV-2 productively infects human gut enterocytes Expression of SARS-CoV-2 entry molecules ACE2 and TMPRSS2 in the gut of patients with IBD This paper was published as part of a supplement financially supported by ECCO and IOIBD. MTA has consulted for Janssen, Prometheus Bioscience, Takeda, Focus Medical Communications, Pfizer, Boehringer Ingelheim Pharmaceuticals, Gilead, Imedex, Cornerstone Health, Inc, Landos Biophama, UCB Biopharma SRL, Eli Lilly, and Cosmo Biopharma. MTA has received grant support from Prometheus Bioscience, Takeda, and Pfizer. L.P.B. has received personal fees from AbbVie, Janssen, Genentech, Ferring, Tillots, Pharmacosmos, Celltrion, Takeda, Boerhinger Ingelheim, Pfizer, Index Pharmaceuticals, Sandoz, Celgene, Biogen, Samsung Bioepis, Alma, Sterna, Nestle, Enterome, Allergan, MSD, Roche, Arena, Gilead, Hikma, Amgen, BMS, Vifor, Norgine; Mylan, Lilly, Fresenius Kabi, Oppilan Pharma, Sublimity Therapeutics, Applied Molecular Transport, OSE Immunotherapeutics, Enthera and Theravance; grants from Abbvie, MSD and Takeda.