Starting a Biologic Therapy in IBD Patients Amid COVID-19: Hold, Careful Monitoring, or Testing?

We have read with interest the recently published viewpoint by Monteleone and Ardizzone[1] on the possible increased risk of contracting COVID-19 in patients with inflammatory bowel disease [IBD]. Consistently with major IBD societies’ recommendations, the authors state that the overall available evidence suggests that IBD patients do not have a baseline increased risk of COVID-19 infection and should stay on IBD medications, with patients receiving immunosuppressive regimens being carefully monitored for the occurrence of symptoms and/or signs suggesting COVID-19.

At the time of writing, the international Surveillance Epidemiology of Coronavirus Under Research Exclusion [SECURE]]-IBD registry has reported 959 cases of COVID-19 in IBD patients, of whom 320 [33%]] were hospitalised and 11 [4%]] died.[2] Also, an Italian study of a series of consecutive IBD patients who developed COVID-19 reported that nearly one-third was hospitalised, with an overall mortality rate of 8%.[3] These figures of negative outcome are in stark contrast to the relatively low infection rate. Thus, as the cases grow worldwide, we believe that particularly caution should be applied in order to prevent complications derived from COVID-19 infection in our IBD patients, especially when treated with immunosuppressive medications.

Although current data do not show an increased risk of negative outcome with concomitant use of immunosuppressive drugs, starting new biologic treatment during the COVID-19 pandemic can be of specific concern to IBD health care professionals. Should we screen IBD patients for COVID-19 infection before starting immunosuppressive therapy? As with many other aspects of COVID-19, data needed to answer this question are limited and currently specific clinical guidance or recommendations are lacking. IBD scientific societies suggest postponing the start of biologic treatment, but there are patients with particularly aggressive clinical flares [i.e. severe ulcerative colitis] who must undergo expeditious treatment. Since this pandemic is unlikely to be quickly contained and delay in biologic therapy initiation in IBD is associated with higher odds of adverse outcomes, indefinite postponement is not a feasible option.

Considering the reported mortality rate due to COVID-19 infection, the frequent chance of absence of respiratory symptoms in patients carrying the virus, the risk of infections, and the potential of a more aggressive course associated with immunosuppressive drugs,[4] we believe that all IBD patients in whom immunosuppressive treatment cannot be delayed should undergo screening for SARS-COV-2 virus active infection, particularly before receiving biologic therapy.[5]

Whether the assessment of immunisation status for effective triage in these patients, and in those already on biologic or immunomodulatory treatment, should be introduced is another crucial clinical question that needs to be addressed in future months.

Funding

None.

Conflict of Interest

Nothing to declare.

Author Contributions

FZ, AB, ES: critical review of manuscript, drafting, and finalisation of the manuscript.