Balancing Risks and Benefits in Inflammatory Bowel Disease Patients during the COVID-19 Pandemic

Dear Editors:

We read with great interest the article by Norsa et al¹ about the outcome of patients with inflammatory bowel disease (IBD) during the novel coronavirus isease-2019 (COVID-19) outbreak in northern Italy.¹ From a total of 522 patients with IBD followed in the unit in Bergamo (22% under use of immunomodulators or steroids and 16% with biologics), there were no reported cases of COVID-19 infection after a follow-up period of approximately 1 month, with no treatment modification or interruption.

Patients with IBD are often being treated with immunomodulators and/or biological agents, which decrease systemic immunity and can possibly increase exposure for viral infections. Therefore, the daily management of patients with IBD can also be affected by the COVID-19 pandemic, as measures towards improved safety and reduced risk of contamination can be undertaken² Any diagnostic or therapeutic intervention in the COVID-19 era can have consequences for patients with IBD.

Social isolation, especially for patients with IBD, which was undertaken in several countries across the globe, aimed to decrease personal travelling and dislocation. Patients in rural areas have to travel to infusion clinics to maintain their therapy. Outpatient visits are usually limited to emergency situations, and the shift to the use of telemedicine in stable patients was a natural consequence of this whole process. Additionally, the interruption of biological therapy, or the switching of intravenous to subcutaneous agents, which are not suggested by IBD experts, aims to keep patients at home and avoid visits to the infusion clinic. These measures can decrease the risk of contamination of COVID-19, but can also increase the risk of an IBD flare with all related consequences. Reorganization of IBD units around the globe needs to be undertaken to face this new reality.^{2 , 3}

Other measures such as delaying the initiation of biological therapy were also speculated in social media and expert discussions. This could theoretically decrease the risk of viral infections, but could also increase the risk of disease progression.⁴ Delaying disease monitoring, with colonoscopies or fecal calprotectin could also increase the possibility of relapse, as a disconnection of IBD-related symptoms and objective parameters is notable in both Crohn’s disease and ulcerative colitis. Delaying elective surgical procedures, aiming for a decrease in the exposure of patients to a possibly contaminated environment, can also lead to disease complications such as the development of stenosis or perforation.⁵

Figure 1 illustrates several interventions in IBD management during the COVID-19 era that may have positive and negative consequences for patients with IBD. Even though decisions in terms of medical therapy could decrease the risk of COVID-19 infection, these measures could also increase the risk of an IBD flare and disease progression. The same is true for surgical procedures, because patients who undergo elective procedures can have an increased risk of severe COVID-19–related complications.⁶

Figure 1.

Inflammatory bowel disease (IBD) therapeutic interventions and possible negative and positive consequences during the novel coronavirus disease-2019 (COVID-19) era. IV, intravenously; SC, subcutaneously.

In the COVID-19 era, the prognosis of patients with IBD can be significantly influenced by therapeutic interventions. The findings from the article by Norsa et al¹ show that keeping medical therapy in patients with IBD can be a safe strategy, despite the short follow-up period of the study. There is a clear need for an individualized approach of IBD interventions in this difficult moment of COVID-19 global pandemic.² Our generation of IBD physicians is learning how to balance difficult decisions at the epicenter of the problem. Involving patients in shared decision making can improve the possibilities of having no negative consequences during this difficult moment for mankind.