AGA Releases COVID-19 Guidelines for IBD Patients

David T. Rubin, MD

Inflammatory bowel disease (IBD) patients are recommended to be particularly careful because of coronavirus disease 2019 (COVID-19) due to the common use of immunosuppressive or immune modifying therapies to treat IBD.

A team, led by David T. Rubin, MD, University of Chicago Medicine Inflammatory Bowel Disease Center, has developed new guidelines for the American Gastroenterology Association (AGA) on how to manage IBD during the COVID-19 pandemic.

The new recommendations suggest patients with IBD should continue IBD therapies, including all scheduled infusions.

Currently, there is no evidence that having IBD increases the risk of a SARS-CoV-2 infection or developing COVID-19.

However, the guidelines recommend for patients with IBD who develop COVID-19 to stop medications such as thiopurines, methotrexate, and tofacitinib, as well as biological therapies including anti-TNF, ustekinumab, and vedolizumab.

The recommendations suggest patients who contract the virus can restart these therapies after the complete resolution of COVID-19 symptoms.

Ultimately, patients should speak with their healthcare team before stopping any medication and doctors should submit cases of IBD and confirmed COVID-19 to the SECURE-IBD registry at COVIDIBD.org.

While the majority of individuals who have COVID-19 experience similar symptoms of a fever and respiratory issues, a significant portion of patients do experience alterations in bowel habits and other digestive symptoms.

These symptoms could reflect inoculation of the gastrointestinal tract from swallowing the virus and because the angiotensin-converting enzyme 2 (ACE2) receptor expression in the intestines.

Recent reports show the virus is detectable in stool long after the resolution of respiratory symptoms or even detection of the virus in the oropharynx.

Recently, the AGA released guidelines suggesting doctors treat all patients like they have COVID-19 and boost personal protective equipment (PPE) regardless of the patient’s COVID-19 status.

The main guidance is that in the absence of accurate and reliable testing for COVID-19, as well as the prolonged asymptomatic shedding prior to exhibiting symptoms, doctors should consider all patients as a risk.

“Data related to the spread of SARS-CoV-2 in the early phase of the pandemic have confirmed that health care professionals are at higher risk of infection than the general population,” the authors wrote. “While COVID-19 is spread primarily through droplet transmission, endoscopic procedures can lead to aerosolization and subsequent airborne transmission.”

The AGA also recommends new practices for PPE for all endoscopic procedures. The new guidelines call for all healthcare workers to us N95, N00, or PAPR masks rather than surgical masks. They also recommend healthcare workers double up on gloves, rather than use single gloves as part of their PPE (RR, 0.36; 95% CI, 0.16-0.78).

Another suggestion for lowering the threat of infection is using negative pressure rooms when available.

The committee also reviewed the data on extended use and re-use of mask and did not find sufficient evidence to comment on the safety on either using masks for up to 8 hours at a time or re-using masks.

For gastrointestinal procedures, the authors recommend triaging procedures to minimize the risk to both healthcare providers and patients and limit the spread of infection.

The IBD guidelines were produced and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board. The new guidelines underwent an internal peer review by the CPUC and an external peer review through standard procedures of Gastroenterology.

“The purpose of this AGA Institute Clinical Practice Update is to rapidly review the emerging evidence and provide timely expert recommendations regarding the management of patients with inflammatory bowel disease during the COVID-19 pandemic,” the authors wrote.

The study, “AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary,” was published online in Gastroenterology.