Guidance for Restarting Inflammatory Bowel Disease Therapy in Patients Who Withheld Immunosuppressant Medications During COVID-19

Abstract

Patients with inflammatory bowel diseases [IBD] are frequently treated with immunosuppressant medications. During the coronavirus disease 2019 [COVID-19] pandemic, recommendations for IBD management have included that patients should stay on their immunosuppressant medications if they are not infected with the severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], but to temporarily hold these medications if symptomatic with COVID-19 or asymptomatic but have tested positive for SARS-CoV-2. As more IBD patients are infected globally, it is important to also understand how to manage IBD medications during convalescence while an individual with IBD is recovering from COVID-19. In this review, we address the differences between a test-based versus a symptoms-based strategy as related to COVID-19, and offer recommendations on when it is appropriate to consider restarting IBD therapy in patients testing positive for SARS-CoV-2 or with clinical symptoms consistent with COVID-19. In general, we recommend a symptoms-based approach, due to the current lack of confidence in the accuracy of available testing and the clinical significance of prolonged detection of virus via molecular testing.

Managing COVID‐19 in patients with inflammatory bowel disease: navigating unprecedented challenges

“…He tested positive after experiencing anosmia and fatigue. He was advised to withhold his azathioprine and adalimumab as suggested by international and local guidelines 2–4 . He remained well without need for hospitalisation.…”

“…Case B acquired COVID‐19 while on adalimumab combination therapy. Current international consensus recommendations state that IBD medications should not be stopped prophylactically in uninfected and asymptomatic patients, but advise withholding immunosuppressants and biologics in active COVID‐19 infection 2–4 …”

“…When recommencing biologics and immunosuppressants post COVID‐19 infection, a symptom‐based strategy taking into consideration the clinical severity of both IBD and COVID‐19 should be adopted 2 . Utilising this strategy, recommencement occurs after at least 10 days from symptom onset, with a minimum of 72 h following infection recovery.…”

“…Utilising this strategy, recommencement occurs after at least 10 days from symptom onset, with a minimum of 72 h following infection recovery. The latter is defined as resolution of fever without the use of fever‐reducing medications and clinical meaningful improvement in respiratory symptoms 2 . Although the SECURE database has been integral in demonstrating the relative safety of continuing biologics during the COVID‐19 pandemic, such retrospective observational data cannot currently inform the safety of intentional biologic continuation in the context of symptomatic COVID‐19.…”

Following Pediatric and Adult IBD Patients through the COVID-19 Pandemic: Changes in Psychosocial Burden and Perception of Infection Risk and Harm over Time

“…During the first infection wave of the pandemic, information on the impact of IBD-medication on risk to acquire the infection, on the severity of disease course and on the mortality from COVID-19 was missing. Over time, data became available from published case series [ 2 ], observational studies [ 3 ], international registries [ 4 , 5 , 6 ] and finally a meta-analysis [ 7 ] that allowed risk estimation for certain drugs and co-morbidities, and the development of recommendations for IBD patients and their health care providers [ 6 , 8 ].…”