An urgent need to institute COVID-19 testing in patients with IBD experiencing flares

We are facing unprecedented challenges during the current coronavirus disease 2019 (COVID-19) pandemic. Management of chronic diseases requiring immunosuppression, such as inflammatory bowel disease (IBD), during this time period has led to difficult and exceptional decision making by both healthcare providers and patients. Decisions with regard to starting or continuing immunosuppression in IBD in both COVID-19 confirmed and suspected patients are done on a case-by-case basis based on pragmatism and experience drawn from other infections. However, our knowledge of COVID-19 is evolving. Rapid mobilisation of efforts globally has led to expert recommendations by various medical societies to help guide clinicians.^{1 2} Furthermore, through commendable efforts made by the IBD community through international registries and regular updates there is now some relative clarity.³

IBD affects over 700 000 people in the UK and forms one of the largest groups of chronic diseases that require immunosuppressive therapies.^{4 5} It is estimated that around 50% of patients experience at least one flare annually. However, it is now evident that digestive symptoms, such as diarrhoea, are often the key presenting feature in nearly half of severe acute respiratory syndrome coronavirus 2 infected patients.^{6 7} Furthermore, diarrhoea may precede onset of any respiratory tract symptoms and is associated with poorer outcomes.

Current UK policies only allow testing for COVID-19 infection in individuals who need admission to hospital or intensive care.⁸ Patients with IBD who have a cough or fever are advised to continue self-isolation on the presumption that their symptoms may be associated with the infection. However, in this context it is now important to consider COVID-19 infections in patients with IBD with exacerbations of their gastrointestinal symptoms. There is preliminary data to support the potential usage of low-dose corticosteroids in the treatment of respiratory coronavirus infections, including COVID-19, severe acute respiratory syndrome and the Middle East respiratory syndrome, through a modulation of the immune response, but this is specific to cases of severe acute respiratory coronavirus and acute lung injury or adult respiratory distress syndrome.^9–12 In the earlier stages of COVID-19 infection, however, it is likely that higher dose steroids, as typically used in management of flare of IBD, are detrimental.^{13 14}

It is therefore essential that before starting steroids if indicated for the treatment of a flare, clinicians can rule out COVID-19 infection. Instituting steroids on the basis of increased diarrhoeal symptoms on the assumption of it being a flare is counterproductive and more likely to result in poorer outcomes. In this difficult period, we urge policymakers in the UK to enable access to COVID-19 testing for such patients. This would facilitate rational and less challenging decision making and would almost certainly reduce inadvertent short-term and long-term repercussions of this pandemic to our patients.