Safe administration of corticosteroids in severe ulcerative colitis and active SARS-CoV2 infection.

Dear Editor,

SARS-CoV2 is a novel coronavirus responsible for a potentially life-threatening infectious disease named COVID-19. Currently, there is no effective treatment for SARS-CoV2, and COVID-19 is managed with symptomatic therapies and supportive care.

In inflammatory bowel disease (IBD), immunosuppressive drugs may increase the risk of infection and/or of severe clinical forms of COVID-19 [1,2]. Therefore, IBD management in patients with concurrent COVID-19 is particularly challenging. International expert recommendations suggest to delay immunosuppressive therapy for at least 2 weeks in patients in remission with active infection [3]. Moreover, the optimal therapeutic strategy for patients with an acute severe ulcerative colitis (UC) and concurrent SARS-CoV2 infection is not established. Intravenous corticosteroids are usually the mainstay treatment for these patients. Recent data associated corticosteroid treatment with a higher patient's mortality compared to anti-TNF antibodies even though a subgroup analysis according to the disease activity (i.e. remission, mild or severe flares) was not performed [4]. Additionally, a letter from Italy reported a severe deadly COVID-19 pneumonia in a 80-year-old woman with a severe UC flare treated by corticosteroids [5].

Recently, we admitted a 20 year-old Somalian woman with UC diagnosed a year earlier, presenting a moderately severe UC flare with intense fatigue, abdominal pain and bloody diarrhoea. The patient was not on maintenance therapy because of a concurrent diagnosis of multidrug resistant miliary tuberculosis. At admission, the Lichtiger score was at 10. Laboratory analysis showed mild anemia and increased C-reactive protein (Table 1 ). A nasal swab for SARS-CoV2 was performed and resulted positive. Stool culture, C. Difficile toxin test and stool SARS-CoV2 RT-PCR were negative. A CT scan showed a pancolitis but no pulmonary lesions suggestive of COVID-19 pneumonia (Fig. 1).

Table 1

Laboratory parameters.

	Day 0	Day 7	Day 12	Day 15
SARS-CoV2 RT-PCR	Positive	Positive	NA	Negative
Treatment	No	5-ASA	CTC	CTC
Hemoglobin (g/dl)	11	10.5	10.1	10
C-reactive protein (mg/l)	18	122	96.5	15.3
Albumin (g/l)	39	34	34	27
Stools/day	9	7	8	6
Bloody stools (%)	<50%	<50%	<50%	0
Lichtiger score	10	13	13	5

5-ASA: 5-aminosalicylic acid; CTC: corticosteroids.

Fig. 1

CT scan showing colitis extended to transverse colon (A, arrows) and hepatic flexure (B, *).

Since systemic corticosteroids use in influenza patients has been associated with a significantly higher risk of lower respiratory tract infection and complications, we first decided to treat the patient with a combination of oral and rectal 5-aminosalicylic acid (4g/day p.o. and 1g/day locally). After 1 week, the patient did not improve and the Lichtiger score increased to 13. A flexible sigmoidoscopy showed a complete vascular pattern obliteration, multiple superficial ulcerations and pseudopolyps (UCEIS: 7/8). A nasal swab for SARS-CoV2 was repeated and resulted positive. As the patient was at low risk of developing a severe form of COVID-19 and her UC severity was worsening, we decided to start methylprednisolone 40 mg/day IV. The patient quickly improved at day 3 (Lichtiger score at 5) and did not develop any COVID-19 symptoms or complications. Laboratory parameters improved significantly (Table 1).

Acute severe ulcerative colitis is a life-threatening complication of UC and intravenous corticosteroids are the first-line therapy. Corticosteroids in IBD patients with SARS-CoV2 infection have been associated initially with worse outcomes [4]. However, in low-risk patients with asymptomatic SARS-CoV2 and acute severe UC, whether the risk associated with corticosteroids overweight the benefit is not clear. Recent data suggest a benefit of dexamethasone on the inflammatory state induced by COVID-19 in patients with respiratory failure [6] even though these results should still be taken with caution due to several study limitations such as the fact that at least 28% of participating patients were still hospitalized at the endpoint of the trial (day 28) [7].

Taking into account risk factors of severe COVID-19 (in particular age) is probably essential before using corticosteroids. In the SECURE-IBD database, 50% of IBD patients who died from COVID-19 and 73% who died and/or needed hospitalisation in an intensive care unit and/or requested invasive ventilation were 60 years or older (respectively 28% and 31% for patient ≥ 80 years old; n=1696) [8]. In our experience, the use of corticosteroids in a young adult patient in the second week of SARS-CoV2 infection was safe and effective for treating an acute severe UC flare.

Author contribution

The authors would particularly thank Doctor S. Tripon, MD and Doctor I. Meriai, MD for their contribution to the redaction of this letter.

Declaration of Competing Interest

None.