Should Patients With Inflammatory Bowel Disease Be Tested for Active COVID-19 Before Starting a Biological Treatment?

Dear Editors:

We read with great interest the review article by Rubin et al¹ aimed to provide recommendations regarding the management of patients with inflammatory bowel disease (IBD) in the era of the coronavirus disease 2019 (COVID-19) pandemic.¹ Given the rapid widespread of this infection from China to many countries in the world and our current knowledge about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), these suggestions regarding patients with important comorbidity, such as immune-mediated diseases, and thus with poorer clinical outcome, are surely very welcome.

In particular, although available data do not support an increased risk of contracting COVID-19 infection in patients with IBD, the international Surveillance Epidemiology of Coronavirus Under Research Exclusion IBD registry reports a not reassuring 4% case fatality rate and hospitalization in nearly one-third of patients.² Moreover, a recent report from Italy showed a case fatality rate of 8% and a hospitalization rate of 28% among 79 patients with IBD with confirmed COVID-19 followed at 24 IBD referral units.³

We appreciate the recommendations by Rubin et al, especially their clarity and practical suggestions. Medication, in particular, is a priority area and the COVID-19 pandemic has led to challenging decision-making about treatment in patients with IBD. The American Gastroenterological Association suggests that patients with IBD should not stop their current treatments to prevent infection or adverse outcome with COVID-19.¹ Considerations on specific drugs were also provided, although robust evidence on the impact of different immunosuppressive or immunomodulatory medications on the COVID-19 related risk is still lacking. However, there was no specific international guidance with respect to COVID-19 testing in patients starting immunosuppressive treatment, particularly if they are asymptomatic, and the article by Rubin et al did not cover this topic either.

Should an asymptomatic patient be tested for SARS-CoV-2 before undergoing the induction regimen of a biologic drug?^{4 , 5} Higher concentrations of biologics are necessary for induction versus maintenance, and induction dosing has been selected to minimize immunogenicity and provide serum levels higher than in maintenance. At this time the potential benefits of testing prior starting a biologic drug are not established, but there is plausible benefit to testing based on the following observations: (1) SARS-CoV-2 infection may be asymptomatic or minimally symptomatic; (2) the potential progression to severe disease of an asymptomatic infection in the setting of intensive immunosuppression; and (3) according to disease severity, the opportunity to delay biologic treatment to allow resolution of SARS-CoV-2 infection. Another important aspect to consider is the contribution of steroids, usually adopted concomitantly with infliximab during induction or as bridge therapy, to the risk of a negative outcome in patients with COVID-19 active infection, as recently demonstrated by Lukin et al,⁶ who showed that baseline disease activity and steroid therapy are the only variables able to stratify the risk of COVID-19 in patients with IBD.

Overall, we believe that screening for active COVID-19 infection should be performed to avoid potential complications and to adjust therapy accordingly prior starting biological treatment. Current recommendations for infection screening should be updated, at least temporarily, and testing for SARS-COV-2 by oropharyngeal swab be included.