We read with great interest the Correspondence from Ping An and colleagues1 regarding protection measures against coronavirus disease 2019 (COVID-19) adopted for patients with inflammatory bowel disease (IBD), in Wuhan, China. The pandemic, caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is rapidly leading to saturation of intensive care units and inpatient beds. The need for full-time physicians and nurses dedicated to patients with COVID-19 is requiring fast and complex reorganisation of clinical activities in many divisions, including IBD units.2, 3
IBDs are immune-mediated diseases, which usually require treatment with corticosteroids, immunomodulators, or monoclonal antibodies to induce and maintain clinical and endoscopic remission. The use of these agents can increase the risk of opportunistic infections, but not that of serious infections. Therefore, adoption of adequate measures to prevent and protect patients is an essential part of the quality standards of care in IBD.
An and colleagues stopped biologics (infliximab infusions) and immunosuppressive treatments for all patients with IBD. This decision is challenging. Indeed, a systematic review4 showed that the risk of hospital admission (odds ratio 0·48, 95% CI 0·29–0·80) and surgery (0·67, 0·46–0·97) is significantly reduced by use of biologics for patients with IBD. The probability of relapse after stopping effective immunomodulators or biological therapy is about 50% and is associated with an increased need for steroids, and risk of hospital admission and surgery.5
Some considerations are needed. First, SARS-CoV-2 infection should be considered as a serious rather than an opportunistic infection, as the risk of infection is not related to concomitant immunosuppression. Second, severe COVID-19 might be associated with cytokine storm and is possibly related to a hyper-immune response in addition to virus-related damage. Third, around 5% of patients who relapse because of withdrawal of effective therapies will require hospital admission against a backdrop of overwhelmed hospital capacity. Thus, the risk and benefits of continuing or stopping biologics should be carefully balanced and should not be assumed to be a general rule for all patients with IBD, especially given the length of time the pandemic is likely to last.
In conclusion, protection of patients with IBD from COVID-19 is crucial and strongly advisable. Whether stopping or adapting therapies will have substantial positive benefits for patients with IBD requires further, longer-term data from different countries.
Acknowledgments
GF reports fees for acting as a speaker, consultant, or advisory board member from AbbVie, Janssen, Ferring, Celltrion, Takeda, Pfizer, Sandoz, Samsung Bioepis, MSD, Roche, Amgen, Vifor, and Mylan, outside the submitted work. LP-B reports grants and personal fees from AbbVie, Takeda, and MSD, personal fees from Janssen, Genentech, Ferring, Tillots, Pharmacosmos, Celltrion, Boerhinger Ingelheim, Pfizer, Index Pharmaceuticals, Sandoz, Celgene, Biogen, Samsung Bioepis, Alma, Sterna, Nestlé, Enterome, Allergan, Roche, Arena, Gilead, Hikma, Amgen, BMS, Vifor, Norgine, Mylan, Lilly, Fresenius Kabi, Oppilan Pharma, Sublimity Therapeutics, Applied Molecular Transport, OSE Immunotherapeutics, Enthera, and Theravance, outside the submitted work. SD reports fees for acting as a speaker, consultant, or advisory board member from AbbVie, Merck and Co, Schering Plough, UCB Pharma, Ferring, Cellerix, Millennium Takeda, Nycomed, Pharmacosmos, Actelion, Alpha Wassermann, Genentech, Grunenthal, Astra Zeneca, Novo Nordisk, Cosmo Pharmaceuticals, Vifor, and Johnson & Johnson, outside the submitted work.
References
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