How to manage inflammatory bowel disease during the COVID-19 pandemic: A guide for the practicing clinician

Table 1 Management of patients attending outpatient clinic with quiescent inflammatory bowel disease in the scenario of asymptomatic severe acute respiratory syndrome coronavirus 2 infection or confirmed or suspected coronavirus disease 2019[12,20,26,27]

	Management
Asymptomatic infection with SARS-CoV-2	(1) Budesonide, aminosalycilates, antibiotics, and topical therapy may be maintained; (2) Hold immunomodulators, tofacitinib, and biologics for 2 wk; (3) Taper or withdraw systemic corticosteroids (prednisone); and (4) Monitoring for 2 wk for COVID-19 symptoms
Mild COVID-19	(1) Budesonide, aminosalycilates, antibiotics, and topical therapy may be maintained; (2) Hold immunomodulators, tofacitinib, and biologics for 2 wk; and (3) Taper or withdraw systemic corticosteroids (prednisone)
COVID-19 with pulmonary involvement without SHS	(1) Budesonide, aminosalycilates, antibiotics, and topical therapy may be maintained; (2) Hold immunomodulators, tofacitinib, and biologics for 2 wk; and (3) Taper or discontinue systemic corticosteroids

Immunomodulators refer to thiopurines and methotrexate. SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; COVID-19: Coronavirus disease 2019; SHS: Systemic hyperinflammation syndrome.

Table 2 Management of patients attending outpatient clinic with mildly active inflammatory bowel disease in the scenario of the asymptomatic severe acute respiratory syndrome coronavirus 2 infection or confirmed or suspected coronavirus disease 2019[12,20,26,27]

	Management
Asymptomatic infection with SARS-CoV-2	(1) Budesonide, aminosalycilates, antibiotics, and topical therapy may be used if needed; (2) Hold immunomodulators, tofacitinib, and biologics for 2 wk; (3) Taper or withdraw corticosteroids (prednisone < 20 mg/d); and (4) Monitoring for 2 wk for COVID-19 to present
Mild COVID-19	(1) Budesonide, aminosalycilates, antibiotics, and topical therapy may be used if needed; (2) Hold immunomodulators, tofacitinib, and biologics for 2 wk; (3) Taper or withdraw systemic corticosteroids); and (4) Monitoring for 2 wk for COVID-19 symptoms to disappear
COVID-19 with pulmonary involvement without SHS	(1) Budesonide, aminosalycilates, antibiotics, and topical therapy may be used if necessary; (2) Hold immunomodulators, tofacitinib, and biologics for at least 2 wk or until COVID-19 resolves; and (3) Taper or withdraw systemic corticosteroids

Immunomodulators refer to thiopurines and methotrexate. SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; COVID-19: Coronavirus disease 2019; SHS: Systemic hyperinflammation syndrome.

Table 3 Management of patients attending outpatient clinic with moderately to severely active inflammatory bowel disease in the scenario of asymptomatic severe acute respiratory syndrome coronavirus 2 infection or confirmed or suspected coronavirus disease 2019[12,20,26,27]

	Management
Asymptomatic infection with SARS-CoV-2	(1) Restrict the use of prednisone ≤ 40 mg/d if necessary; (2) Avoid immunomodulators and tofacitinib; (3) Escalate to biologics as necessary (preferably in monotherapy); and (4) Thromboprophylaxis
Mild COVID-19	(1) Restrict the use of prednisone ≤ 40 mg/d if necessary; (2) Avoid starting or stopping, if in use, immunomodulators, and tofacitinib; (3) Escalate to biologics and dose optimization as necessary (preferably in monotherapy); and (4) Thromboprophylaxis
COVID-19 with pulmonary involvement without SHS	(1) Restrict the use of prednisone ≤ 40 mg/d if necessary; (2) Avoid starting or stopping immunomodulators, and tofacitinib; (3) Escalate to biologics and dose optimization as necessary (preferably) in monotherapy based on balance of benefits and risks; consultation with infectious diseases expert for possible COVID-19 treatment with antiviral or experimental anticitokine therapy; and (4) Thromboprophylaxis

Immunomodulators refer to thiopurines and methotrexate. SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; COVID-19: Coronavirus disease 2019; SHS: Systemic hyperinflammation syndrome.

Table 4 Management of patient with inflammatory bowel disease hospitalized with severe coronavirus disease 2019[12,19,20,26,27]

	Management
Quiescent IBD	(1) Budesonide, aminosalycilates, and rectal therapy may be kept; (2) Taper or withdraw prednisone; (3) Stop immunomodulators, tofacitinib, and biologics; and (4) Prioritize life support; consultation with infectious diseases expert for possible COVID-19 treatment with antiviral or experimental anticitokine therapy; thromboprophylaxis
Mildly active IBD	(1) Budesonide, aminosalycilates, and rectal therapy may be initiated; (2) Taper or withdraw prednisone; (3) Non starting or stopping if in use biologics, immunomodulators, and tofacitinib; and (4) Prioritize life support; consultation with infectious diseases expert for possible COVID-19 treatment with antiviral or experimental anticitokine therapy; thromboprophylaxis
Moderately to severely active IBD	(1) Limited use of intravenous steroids for IBD if necessary; (2) Topical therapy may be initiated if needed; (3) Quit immunomodulators, tofacitinib, or biologics that failed for the IBD; and (4) Consider other therapies for IBD only if absolutely necessary; intravenous cyclosporine may be a reasonable option for ulcerative colitis, based on limited evidence of its benefit against coronavirus. Prioritize life support; consultation with infectious diseases expert for possible COVID-19 treatment with antiviral or experimental anticitokine therapy; thromboprophylaxis

Immunomodulators refer to thiopurines and methotrexate. IBD: Inflammatory bowel disease; COVID-19: Coronavirus disease 2019; Severe COVID-19: Patient with systemic hyperinflammation syndrome needing mechanical ventilation ± vasopressors or evidence of end organ damage.

Table 5 Approach to diminish the spread of coronavirus disease 2019 for patients with inflammatory bowel disease[10]

	Approach to diminish the spread of COVID-19 for patients with IBD
Inpatient clinic	(1) Hospitalized patients with IBD relocated to an isolated area/building, if possible, minimizing exposure to the virus; and (2) Test for coronavirus 2019 with nasopharyngeal swabs (PCR) before hospitalization
Outpatient clinic	(1) Visits rescheduled if possible; (2) Medical staff monitor patients via telemedicine (e.g., remote video and telephone call); (3) Laboratory tests strictly limited; use fecal calprotectin (home modality, stool collection kit picked up by express mail services, if possible); (4) Endoscopy and image procedures only for urgent cases; (5) Patients should be advised to keep hygienic measures, avoid nonessential travels, and stay at home or work on a home-office basis; (6) Recommendations to maintain adequate hydration and nutrition status; and (7) Advise patients to continue their therapies, especially if in remission
Infusion center	(1) No accompanying person permitted; (2) Rearrangement of seats allowing a distance of at least 1.5 m in between; (3) Surgical masks for both patients and healthcare professionals; (4) Pre-admission protocol to assess for acute respiratory tract symptoms among patients with IBD and their contacts; (5) Selection of patients that could have their infusion postponed for 1-2 wk to let more space available for rearrangements of seats (those with clinical and endoscopic remission); and (6) Preference, if possible, for those biologics that can be offered subcutaneously, at home, instead of intravenously, to avoid overcrowding in the infusion center

IBD: Inflammatory bowel disease; COVID-19: Coronavirus disease 2019; PCR: Polymerase chain reaction.

Table 6 Category of endoscopic procedures[13,62]

Emergent endoscopy	Urgent endoscopy	Elective endoscopy
Ascending/acute cholangitis; Foreign body retrieval; GI obstruction; Life-threatening GI bleeding	Cancer staging; Stable GI bleeding; Tumor biopsy; Palliative procedures (stenting, neurolysis); Planned EMR/ESD for complex/high-risk lesions	Biliary stent removal; Clinical trials; Colorectal cancer screening; Percutaneous endoscopic gastrostomy; Post-polypectomy surveillance; Surveillance/follow-up endoscopy (excluding high-risk neoplasia)

GI: Gastrointestinal; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection.

Table 7 Indications for gastrointestinal endoscopy in patients with inflammatory bowel disease during the coronavirus disease 2019 pandemic[57,63,64]

Recommended	Considered case-by-case	Postpone
Confirm IBD diagnosis in patients with moderate to severe activity; Acute severe ulcerative colitis; Partial GI obstruction; Life-threatening GI bleeding; Worsening cholangitis and jaundice in patients with IBD and PSC with a dominant bile duct stricture	Surveillance colonoscopies of high-risk patients; Specific clinical trials	Confirm IBD diagnosis in patients with mild symptoms; Monitoring IBD treatment; Postoperative recurrence assessment; Surveillance colonoscopies of low-risk patients; Clinical trials

GI: Gastrointestinal; IBD: Inflammatory bowel disease; PSC: Primary sclerosing cholangitis.