Impact of COVID-19 on inflammatory bowel disease practice and perspectives for the future

Table 1 British Society of Gastroenterology stratification of inflammatory bowel disease patients according to the risk of severe acute respiratory syndrome coronavirus 2 infection

Highest risk patients“shielding indicated”	Moderate risk patients“stringent social distancing”	Lowest risk patients“social distancing”
Patients who either have a comorbidity (respiratory, cardiac, hypertension or diabetes mellitus) and/or age ≥ 70 yr old and are on any “moderate risk” therapy for IBD (per middle column) and/or have moderate to severely active disease.	Patients with moderate to severely active disease who are not on any of the medications in this column. Patients on the following medications: (1) anti-TNF (infliximab, adalimumab, golimumab) monotherapy; (2) biologic plus immunomodulatory in stable patients; (3) ustekinumab; (4) vedolizumab; (5) Thiopurines (azathioprine, mercaptopurine, tioguanine); (6) methotrexate; (7) calcineurin inhibitors (tacrolimus or ciclosporin); (8) JAK inhibitors (tofacitinib); (9) immunosuppressive trial medication; (10) mycophenolate mofetil; (11) thalidomide; and (12) prednisolone > 20 mg or equivalent per day	Patients on the following medications: (1) 5ASA; (2) rectal therapies; (3) orally administered topically acting steroids (budesonide or beclometasone); (4) therapies for bile acid diarrhea (colestyramine, colesevelam, colestipol); (5) anti-diarrheals (e.g., loperamide); and (6) antibiotics for bacterial overgrowth or perianal disease
Patients of any age regardless of comorbidities and who meet one or more of the following: (1) intravenous or oral steroids ≥ 20 mg prednisolone or equivalent per day (only while on this dose); (2) began biologic plus immunomodulator or systemic steroids within previous 6 wk; (3) moderate-to-severe active disease not controlled by “moderate risk” treatments; (4) short bowel syndrome requiring nutritional support; and (5) requirement for parenteral nutrition

5ASA: 5-aminosalicylic acid; IBD: Inflammatory bowel diseases; JAK: Janus kinase; TNF: Tumor necrosis factor.

Table 2 Summary of treatment in severe acute respiratory syndrome coronavirus-2 negative patients with stable inflammatory bowel disease disease course

Drug	Suggestions	Additional comments
	Continue therapy
Salicylates	Yes	Data from the SECURE-IBD of possible harm need to be confirmed.
Locally acting steroids	Yes	No specific data available
Systemic steroids	Yes	Limit use to strictly necessary and taper rapidly
Azathioprine	Yes	Data from the SECURE-IBD of possible harm need to be confirmed, the risk of reactivation seems to outweigh the risk of continued treatment
Methotrexate	Yes	Limited data available
Anti-TNF	Yes	Data from the SECURE-IBD indicate better outcomes compared to other treatments; there are ongoing trials for the treatment of COVID-19
Vedolizumab, anti-IL-12/23	Yes	Limited data available
Tofacitinib	Yes	Limited data available

COVID-19: Coronavirus disease 2019; IBD: Inflammatory bowel diseases; IL: Interleukin; TNF: Tumor necrosis factors.

Table 3 Summary of treatment in severe acute respiratory syndrome coronavirus-2 positive patients with stable inflammatory bowel disease disease course

Drug	Suggestions	Additional comments
	Continue therapy
Salicylates	Yes	A pause can be considered since data suggest a possible association of their use and poor COVID-19 outcome
Locally acting steroids	Yes	No data available
Systemic steroids	Rapid tapering	Dosage below 40 mg/d is suggested along with rapid tapering, particularly in patients without pneumonia and need for oxygen supplementation
Azathioprine	No	Delay treatment for 2 wk and/or until COVID-19 symptoms resolve
Methotrexate	No	Delay treatment for 2 wk and/or until COVID-19 symptoms resolve
Anti-TNF	No	Delay treatment for 2 wk and/or until COVID-19 symptoms resolve. Continued therapy may be considered in selected patients since no data demonstrated adverse outcome to date.
Vedolizumab, anti-IL-12/23	No	Delay treatment for 2 wk and/or until COVID-19 symptoms resolve
Janus kinase inhibitors	No	Delay treatment for 2 wk and/or until COVID-19 symptoms resolve

COVID-19: Coronavirus disease 2019; IL: Interleukin; TNF: Tumor necrosis factors.