Severe Ulcerative Colitis Management During COVID-19

Shaji Sebastian, MD

Despite changes that have been made during the coronavirus pandemic to manage acute severe ulcerative colitis, there seems to be low risk for COVID-19 infection post-hospitalization or severe COVID-19 for these patients, according to a paper published in The Lancet Gastroenterology & Hepatology.

Investigators from the UK conducted an observational case-control study across 60 acute secondary care hospitals in order to identify changes to care for severe ulcerative colitis during the ongoing COVID-19 pandemic and the effect on outcomes. The team wanted to determine the proportion of patients with severe disease who received rescue therapy or colectomy.

The 782 adult patients involved in the analysis presented either with ulcerative colitis or inflammatory bowel disease. There were 398 patients seen in the pre-pandemic period, defined as January-June 2019, and 384 patients seen in the pandemic period, defined as March-June 2020.

At baseline, the study authors described the 2 cohorts’ demographics and disease characteristics as similar. At the time of presentation with severe ulcerative colitis, a higher proportion of patients in the pandemic period were receiving oral steroids, rectal steroids, and biological or small molecule therapies compared to the historical, comparison cohort.

The median duration of oral steroids before meeting acute criteria was longer for the pandemic cohort compared to the statistical cohort, the investigators also learned (14 days vs. 13.5 days, respectively). The investigators wrote that there was no difference in the use of oral or topical mesalazines or thiopurines between the 2 cohorts, nor was there a difference among oral steroid users between the groups, such as prednisolone or poorly bioavailable steroid.

The 2 cohorts had no observable differences at days 1, 3, or 5 in terms of markers of acute severe ulcerative colitis severity, except for serum albumin levels, which were lower in the pandemic cohort. This group also demonstrated a higher proportion of patients who were managed initially on an ambulatory pathway compared to the historical group, but 84% of the ambulatory patients required inpatient admission compared to 95% of ambulatory patients during the historical cohort. The study authors found that patients were less likely to present emergently to the emergency room in the pandemic period compared to the historical cohort.

Rescue therapy was more common during the pandemic period compared to the historical group, primarily caused by a greater use of rescue and primary induction therapies with biologicals, ciclosporin, or tofacitinib in the pandemic group compared to the comparison group. The researchers also noted that there was no difference in the requirement for emergency surgery between the cohorts.

During the pandemic, rescue therapy or surgery happened at a higher rate and more quickly compared to the historical group. Additionally, time to rescue therapy or surgery was shorter in the pandemic, but overall response to rescue therapy was similar between the groups. There was also no difference in time to surgery between groups.

After 3 months, there was no observed difference between the proportion of patients in symptomatic, biochemical, or endoscopic remission, the study authors wrote based on follow-up data available for 697 total patients. There were also no serious COVID-19 outcomes.

“Although there have been some adaptations to conventional management of patients during the pandemic… these did not lead to different acute severe ulcerative colitis outcomes for patients,” the study authors concluded. “Use of cornerstone medications, such as high-dose intravenous steroids and biologicals, in acute severe ulcerative colitis appears to pose a low risk of nosocomial and post-discharge acquisition of SARS-CoV-2 and of developing severe COVID-19.”