Inflammatory Bowel Disease Management in a Major Referral Center During COVID-19 Pandemic.

To the Editors,

We read with great interest the manuscript by Axelrad et al[1] summarizing the characteristics of patients with inflammatory bowel disease (IBD) and coronavirus 2019 (COVID-19). We share with the authors the concern with IBD patients. Thus, our department established strategies to prioritize the care of these individuals, which were implemented on our practice by March 18, 2020, and were in course until the end of the state of emergency. Herein, we briefly describe the measures implemented and the obtained outcomes.

Most medical appointments were made by phone, and we ensured that patients had essential medications. To prevent disease flares, their usual therapy was maintained. The exception was for those who were under high-dose steroids (>20 mg/day), whose tapering was made as quickly as possible. In the case of IBD flare, the therapies commonly used in these circumstances were initiated.[2] We modified our day care unit to ensure that patients kept their usual biologic medication safely; systematic screening for symptoms and fever was performed before treatments. We postponed all elective procedures, and endoscopy was performed only in urgent cases.[3] All patients who were proposed for endoscopic procedures were previously tested for SARS-CoV-2, and health professionals always used protective equipment during procedures. Individuals who were admitted had been tested for SARS-CoV-2, allowing the creation of COVID-19 and COVID-19-free wards. A set of measures to prevent SARS-CoV-2 infection during hospitalizations were implemented, namely forbidding visits and reducing the number of patients per ward.

Over the period of the state of emergency, we achieved a rate of almost 95% of medical appointments by telemedicine and therapeutic compliance in 90% of cases. Our patients did not self-medicate and sought information about their IBD care by contacting our medical services or attending the emergency department. There was no significant increase in the rate of hospital admissions due to IBD decompensation compared with the same period last year. There were 1990 SARS-CoV-2 infections diagnosticated in our hospital, and 11 patients had IBD (Table 1). None of these patients had acute decompensation of IBD, and no deaths were reported. Thiopurines and biological therapies were suspended during the viral illness and restarted after complete symptoms resolution or when SARS-CoV-2 retesting was negative.

TABLE 1.

Characteristics of IBD Patients with Infection by COVID-19

Patient	Age (years)	Sex	IBD	CD Montreal phenotype	UC extension	Disease activity	Therapy	Comorbidities	Symptoms	CT findings	Therapies for COVID-19	Hospitalization	ICU admission	Death
1	50	F	CD	A2L2B3	—	Remission	Azathioprine	Hypertension, dyslipidemia, asthma	Fever, cough, myalgia, fatigue	ND	ND	No	No	No
2	41	M	CD	A2L1B3	—	Remission	None	No	Fever, sore throat, headache	ND	ND	No	No	No
3	65	M	CD	A3L1B1	—	Remission	None	Hypertension, dyslipidemia, diabetes	Cough, headache, myalgia	ND	ND	No	No	No
4	21	M	CD	A2L2B1	—	Remission	Infliximab	No	Headache, anosmia, dysgeusia	ND	ND	No	No	No
5	44	F	CD	A2L1B3	—	Active	Azathioprine	CV disease, Asthma	Fatigue, anosmia, dysgeusia	ND	ND	No	No	No
6	24	F	UC	—	Left-sided	Active	Mercaptopurine	No	Fever, sore throat, rhinorrhea, myalgia, fatigue, headache	ND	ND	No	No	No
7	61	M	CD	A1L3B2	—	Remission	Infliximab	No	Fever, cough, headache, nausea/vomiting, anosmia	Bilateral pneumonia	5-day HCQ	Yes	No	No
8	46	M	CD	A3L1B1	—	Remission	Adalimumab	No	Cough	ND	ND	No	No	No
9	54	F	CD	A2L1B2	—	Active	Azathioprine	Hypertension	Cough, fever, fatigue	ND	ND	No	No	No
10	49	F	UC	—	Extensive	Remission	Infliximab, Mesalazine	Porphyria cutanea tarda	Sore throat, fatigue, diarrhea	ND	ND	No	No	No
11	30	F	CD	A2L3B1	—	Active	Adalimumab	No	Cough, fever, fatigue	ND	ND	No	No	No

Abbreviations: CD, Crohn’s disease; UC, ulcerative colitis; CT, computed tomography; ICU, intensive care unit; F, female; M, male; Montreal classification: age of onset (A): A1, 16 years or younger; A2, 17–40 years; A3, above 40 years; disease location (L): L1, terminal ileum; L2, colon; L3, ileocolon; L4, upper gastrointestinal tract; disease behaviour (B): B1, nonstricturing nonpenetrating; B2, structuring; B3, penetrating; CV, cardiovascular; ND, not done; HCQ, hydroxychloroquine. Note: Active disease was determined by a partial Mayo score >1 for UC and Harvey-Bradshaw index >4 for CD.[2]

Our protocol showed that the level of care for IBD patients could be maintained during the pandemic. The risk of developing severe COVID-19 seems to be similar to the general population; however, it is suggested to keep close surveillance of these patients.