COVID-19 (Coronavirus) and IBD: Resources for Healthcare Professionals

This page is intended to provide an overview of the key information about COVID-19 (coronavirus) and IBD specific recommendations for professionals leveraging the CDC, WHO, FDA and other agency recommendations. We've also included details from recently published articles along with links to the full texts. The information on this page has been reviewed by leadership from the Crohn’s & Colitis Foundation National Scientific Advisory Committee. Please note that information is evolving and this page may be updated frequently.


Jump to:

High risk groups | Medication updates | Medication and supplies | COVID-19 and the GI tract | GI society joint message | Guidance on facemasks  | SECURE-IBD registry | SECURE-EOE/EGID registry | Patient presentation template

High risk groups

The information that is known so far about COVID-19 is based on what has been reported from cases in Wuhan, China, and we are learning more as the virus has spread to other countries. Based on the reported cases, we know that there may be individuals that are at higher risk. Individuals in high risk groups defined by the CDC are being advised to take extra precautions. The specific recommendations from the CDC regarding high risk groups, and from the Lancet regarding IBD patients, are listed below:

  • Adults over 60, especially men 
  • Individuals with underlying health conditions like heart disease, lung disease (including asthma), diabetes, chronic kidney disease, chronic liver disease, endocrine and metabolic disorders, neurological, neurologic and neurodevelopment conditions
  • Potential risk factors:
    • Individuals who are pregnant or had a recent pregnancy
    • Individuals with weakened immune systems

At this point the data does not indicate that patients with IBD have an increased risk of infection with SARS-CoV-2 and/or development of COVID-19.3

Resources:

Updates and recommendations on IBD medications

The AGA Institute Clinical Practice Updates Committee advises patients with IBD to continue to maintain or achieve remission to avoid potential relapse and, as a result, a potential intensification of therapy or hospitalization.The International Organization for Study of Inflammatory Bowel Disease (IOIBD) issued specific guidance on the novel coronavirus, named SARS-CoV-2, as it relates to IBD medications. See summary of the guidance below.

  • Encourage your patients to stay on their IBD medications
  • Amino salicylates (Asacol®, Apriso™, Canasa®, Delzicol™, Lialda™, Pentasa®, Rowasa®) are all safe and are not considered immune suppressant medications.
  • Patients on steroids (prednisone/prednisolone) are immune suppressed.  These patients should take extra precautions by following the CDC’s recommendations for risk reduction 
    • Discuss with your patient opportunities to reduce dose or get off steroids (prednisone/prednisolone) which is always a recommendation in managing IBD.
  • Immunomodulators like thiopurines (azathioprine, 6-mercaptopurine, cyclosporine, methotrexate), and the JAK inhibitor tofacitinib (Xeljanz®) tend to inhibit the body’s immune response to viral infections 
    • Patients should not stop taking these medications. Encourage your patients to follow CDC recommendations for risk reduction.
  • Biologics/Biosimilars including certolizumab pegol (Cimzia®), adalimumab (Humira®), infliximab (Remicade®), golimumab (Simponi®), infliximab-abda (Renflexis®), infliximab-dyyb (Inflectra®), infliximab-qbtx (Xifi™), ustekinumab (Stelara®), and vedolizumab (Entyvio®) are immune suppressing drugs (see our biologics factsheet for a full listing of anti-TNFs and other biologic therapies):
    • Encourage your patients to continue taking these medications.

Reference IOIBDhttps://www.ioibd.org/ioibd-update-on-covid19-for-patients-with-crohns-disease-and-ulcerative-colitis/

The AGA Institute Clinical Practice Updates Committee has developed guidance for therapy management in IBD into three categories: 

  1. The patient with IBD who is NOT infected with SARS-CoV-2
  2. The patient with IBD who is infected with SARS-CoV-2 and asymptomatic (e.g. IBD is in remission and has not developed manifestations of COVID-19) 
  3. The patient with IBD who has confirmed COVID-19, with or without active bowel inflammation or other digestive symptoms.

Reference article and figurehttps://doi.org/10.1053/j.gastro.2020.04.012

IBD medication: travel and large event recommendations

  • Your patients on mesalamine should follow the CDC and their public health department’s guidance related to events and travel
    • The SECURE-IBD Registry did observe that patients exposed to 5-ASA/sulfasalazine were associated with more severe COVID-19.4 
    • Mesalamine medications are in the aminosalicylate category and include: (Asacol®, Apriso™, Canasa®, Delzicol™, Lialda™, Pentasa®, Rowasa®)
  • Patients on immunosuppressants and biologics/biosimilars are encouraged not to travel or gather in large numbers. The common immunosuppressing drugs and biologics/biosimilars are listed below:
    • Immunomodulators: Azathioprine (Azasan®, Imuran®, cyclosporine (Gengraf®, Neoral®, Sandimmune®), mercaptopurine (Purinethol®), methotrexate (Rheumatrex®), tacrolimus (Prograf®)
    • Biologics/biosimilars: According to the SECURE-IBD Registry data, these therapies were not found to be an independent risk factor for more severe COVID-19.4 Anti-TNF biologics include certolizumab pegol (Cimzia®),adalimumab (Humira®), infliximab (Remicade®), golimumab (Simponi®), infliximab-abda (Renflexis®), infliximab-dyyb (Inflectra®), infliximab-qbtx (Xifi™). Other biologics include integrin receptor antagonists like natalizumab (Tysabri®) and vedolizumab (Entyvio®), and interleukin 12 and 23 antagonists like ustekinumab (Stelara®). 
    • Steroids: According to the SECURE-IBD Registry data, steroids did have an association with adverse COVID-19 outcomes.4 Budesonide (Entocort® EC, UCERIS™), methylprednisolone (A-Methapred®, Depo-Medrol®, Medrol Dosepak®, Solu-Medrol®), prednisolone (Orapred®, Prelone®, Pediapred®), prednisone (Deltasone®).
    • JAK inhibitors: Tofacitinib (Xeljanz®)
  • The CDC has issued community mitigation strategies for schools, workplace and community/places of worship.  
    • Guidance includes a range of strategies from minimal, moderate to sustainable 
    • Guidance takes into account the uniqueness of each community and the need to implement strategies specific to the community
    • CDC recommends individuals on immune suppressive drugs not participate in events with greater than 10 people in attendance.

Reference: SECURE-IBD article

Click here for CDC Mitigation guidance 

Medication and supplies

The CDC recommends that people have their medicine cabinets stocked with supplies and essentials during any type of natural disaster or emergency. This includes medicine such as cough syrup, cold and flu medicine, and other items that are typically available to help with the symptoms of a cold or virus. Many of your IBD patients are concerned about access to medications in the event of a supply shortage. The FDA is closely monitoring the medical supply chain, and there have been no shortages reported to date on medications used to treat IBD. 

Please encourage your patients to contact their insurance company for specific policies related to testing, prescription refills and other support. For patients without insurance or in need of additional insurance-related guidance, the National Association of Insurance Commissioners has compiled a comprehensive list of resources by state. Please encourage your patients and support staff to visit: https://content.naic.org/naic_coronavirus_info.htm, go to “Resources” and navigate by state. You can also encourage your patients to contact the IBD Help Center with additional questions.

Research on COVID-19 and the GI tract

According to several papers published in the journal Gastroenterology, patients with COVID-19 may also experience gastrointestinal symptoms, including diarrhea, nausea, vomiting and abdominal discomfort prior to the common respiratory symptoms1,2. The gastrointestinal symptoms that have been observed globally are less common and there is variability based on the populations/cases that were observed.

Key Findings:

  • GI symptoms including diarrhea, nausea, vomiting and/or abdominal discomfort appeared before respiratory symptoms
  • It is recommended patients be monitored if they present with initial GI distress, encouraging earlier detection, diagnosis, intervention and isolation
  • Viral RNA is detectable in stool of those suspected to have COVID-19; virus sheds into the stool
  • GI symptoms have not been found to have a clear association with the presence of viral RNA in the stool
  • Viral gastrointestinal infection and potential fecal-oral transmission can last even after viral clearance in respiratory tract
  • Prevention of fecal-oral transmission should be taken into consideration to control the spread the virus

The Lancet published new information from China on the implications of COVID-19 on digestive diseases, including IBD. The article, linked below, includes specific guidance regarding medications, diet and postponement of elective surgery. In addition, the article shares strategies used to mitigate exposure to SARS-CoV-2 by using telemedicine and online consulting by IBD specialists. 

References: 

https://www.eurekalert.org/pub_releases/2020-03/aga-gsa030520.php

https://www.thelancet.com/journals/langas/article/PIIS2468-1253(20)30076-5/fulltext#.XmmARom8_x4.twitter

Recommendations for GI endoscopy and clinic practices

A joint GI society message (AASLD, ACG, AGA, and ASGE) for gastroenterologists and gastroenterology care providers was issued on March 15, 2020. Recommendations include:

  • Pre-screen all patients for high risk exposure or symptoms. Patients should be asked about history of fever or respiratory symptoms, family members or close contacts with similar symptoms, any contact with a confirmed case of COVID-19, and recent travel to a high-risk area. 
  • Avoid bringing patients (or their escorts) into the medical facility who are over age 65 or have one of the CDC recognized risks listed above. 

You can read their full joint guidance at any of the society websites: AASLD, ACG, AGA or ASGE websites.

Guidance on facemasks 

The CDC has provided strategies for optimizing the supply of facemasks for consideration by federal, state, and local public health officials as well as healthcare leaders to help create policies and procedures for preventing the transmission of SARS-CoV-2 in a healthcare setting; many states have adopted these recommendations as well. Decision makers at gastroenterology offices and infusion centers can also use CDC guidance to help evaluate their role.

Take action: SECURE-IBD registry

Healthcare providers register ALL cases of COVID-19 in IBD patients

Questions regarding the impact of COVID-19 on IBD patients such as age, comorbidities, and IBD treatments are emerging. The SECURE-IBD (Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE)-IBD registry) is available for all IBD professionals to register their patients with COVID-19 so we can better understand the impact of COVID-19 on IBD patients. The registry is de-identified and takes 5 minutes to complete. To learn more visit: https://covidibd.org/

The Foundation recently hosted a Facebook Live event to share the SECURE-IBD registry findings with patients. You can view the program here.

Take action: SECURE-EOE/EGID registry

Healthcare providers register all cases of COVID-19 in EOE and EGID patients

The SECURE-EOE/EGIG registry has been developed to collect information on patients previously diagnosed with Eosinophilic Esophagitis (EoE) and Eosinophilic Gastrointestinal Diseases (EGID) who are under high suspicion or confirmed with a diagnosis of COVID-19. The registry is de-identified and takes 5 minutes to complete. To learn more visit: https://eureos.online/files/content/News/SECURE-EoE-EGID%20COVID19%20letter%2028.3.2020.pdf

Presentation template for patients

The Foundation has worked with our National Scientific Advisory Committee to develop a slide presentation that you can refer to when discussing COVID-19 with your IBD patients. Click here to view and download the slides.

See additional guidance and resources: 

This information was developed by members of the National Scientific Advisory Committee.

Last updated July 2020

 

References

1. Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroentrology, 2020. Article in press. https://www.gastrojournal.org/article/S0016-5085(20)30281-X/pdf. Accessed March 6, 2020

2. Xiao F, Tang M, Zheng X, Liu Y, Li, X, Shan H. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology, 2020. Article in press. https://www.gastrojournal.org/article/S0016-5085(20)30282-1/pdf Accessed March 6, 2020.

3. Rubin DT, Feuerstein JD, Wang AY, Cohen RD, AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary, Gastroenterology (2020), doi: https://doi.org/10.1053/j.gastro.2020.04.012

4. Brenner EJ, Ungaro RC, Gearry RB, et al. Corticosteroids, but not TNF Antagonists, are Associated with Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results from an International Registry. Gastroenterology. 2020;0(0). doi: https://doi.org/10.1053/j.gastro.2020.05.032   

https://www.ioibd.org/ioibd-update-on-covid19-for-patients-with-crohns-disease-and-ulcerative-colitis/

https://www.eurekalert.org/pub_releases/2020-03/aga-gsa030520.php

https://www.thelancet.com/journals/langas/article/PIIS2468-1253(20)30076-5/fulltext#.XmmARom8_x4.twitter

Joint GI Society Message: COVID-19 clinical insights for our community of gastroenterologists and gastroenterology care providers issued March 15, 2020 by AASLD, ACG, AGA and ASGE.