Keeping on the High Quality of Health Care in Greek Inflammatory Bowel Disease Patients in the SARS-CoV-2 Era.

Dear Editor:

It was with great interest that we read the article by Allocca et al describing the management strategy, amid COVID-19 pandemic, by 1 of the largest tertiary referral inflammatory bowel disease (IBD) centers in Europe. This report is of even greatest importance considering the high burden of COVID-19 in Italy.

Since the very beginning of COVID-19, things regarding the management of patients with IBD have dramatically changed. To protect patients during this critical situation, colleagues from Wuhan implemented early cessation of biologic agents and immunosuppressants. No COVID-19 infection was reported but the effect of this drug holiday on the disease course remains to be seen. However, in Bergamo, Italy, 522 patients maintained their therapy and there was no COVID-19 occurrence. In a worldwide registry only 8 children with IBD were found to be COVID-19 positive; all developed mild disease. Moreover, in 22% of the children whose treatment was delayed or discontinued a disease flare was observed.

Meanwhile first recorded data from the SECURE-IBD Database showed that the proportion of critically ill patients (intensive care unit/ventilator 10%) and deaths (3%) among patients with IBD are similar to those of the general population. Consequently, recommendations from experts and organizations (International Organization for the Study of Inflammatory Bowel Diseases, European Crohn’s and Colitis Organization) have emerged aiming to help health care physicians cope with this unpredictable situation. ,

We share our experience, describing readjustments in the structure of our IBD clinic and patient management that became necessary since the first cases of COVID-19 have been identified in our region (Crete, Greece).

Our IBD team consists of 3 gastroenterologists, 1 IBD nurse, and 1 trial coordinator. In the new era of SARS-CoV-2 we altered our weekly activities, which were normally composed of 1 outpatient IBD visit clinic, 1 endoscopy IBD day, 5 of 1-day care for biologic treatments, and 5 every day active clinical trial department. Our IBD database includes 890 patients (164 in biologics).

We had to reconsider the structure of the clinic and reschedule all daily activities since March 16, 2020. At that time point, 352 total COVID-19-positive cases have been identified (5 deaths) and the Greek ministry of health and civil protections applied the national lockdown restrictions. We followed the International Organization for the Study of Inflammatory Bowel Diseases recommendations. We urged patients, without COVID-19 suspicion, to stick to their treatment schedule either for intravenous infusion or for subcutaneous and per os medications but avoided initiation of steroid treatment. Starting from March 16 until April 16, 2020, 78 outpatient IBD clinic visits had scheduled appointments. Of the total 78 patients, 67 patients (85.9%) were virtually followed-up and reached through telephone. Among these patients, 3 stopped their treatment (2 immunomodulator and 1 biologic) on their own, whereas 2 experienced stress that required psychiatric consultation and treatment.

Regarding the prescription of medications, patients received their prescriptions either in their cellphone or in their e-mail. A new helpline was established and we have received more than 100 telephone calls from patients with IBD. During all telephone calls, patients were offered detailed instructions concerning everyday preventive measures and were also advised not to modify their treatment unless any complication occurred. Moreover, they were provided via e-mail informative material published by the national IBD team and per request a medical note describing their medical history and current condition recommending the employers if possible to place employees in a position so as to work from home.

The access to the clinic was restricted only to emergency admissions, patients receiving infusions, and clinical trial patients. Out of 64 scheduled biologic infusions in the 1-day care department, 58 patients (90.6%) received their infusion timely, whereas 4 (6.3%) received their infusion a few days later; only 2 (3.1%) did not attend their appointment. Ten patients were hospitalized during this period. Among them there were 4 patients (3 ulcerative colitis, 1 Crohn’s disease) who had severe active IBD, 1 had stopped previously prescribed medication (azathioprine) on his own, and all were started on biologic treatment (3 infliximab, 1 adalimumab).

Eleven patients (100%) who were enrolled in interventional clinical trials attended their scheduled treatment, 1 patient previously screened was successfully randomized in the clinical trial, and 2 screening procedures cancelled. All endoscopy procedures were cancelled but the emergency ones were performed taking all the required protective measures per protocol.

As of April 17, 2020 none of our patients with IBD reported alarming respiratory symptoms or developed COVID-19 infection.