Acute severe ulcerative colitis: confronting an intensified stressor during the COVID-19 pandemic

COVID-19 has been a threat multiplier that affects all aspects of life. The medical and psychosocioeconomic effects of the COVID-19 pandemic and pre-existing medical conditions such as acute severe ulcerative colitis are multidirectional, and include the impacts of COVID-19 and acute severe ulcerative colitis on each other, and their influences on the welfare of patients, their families, health-care providers, and the health-care system. The risk of adverse outcomes of COVID-19 has been reported to be higher in patients with ulcerative colitis than in patients with Crohn's disease.¹ The management of acute severe ulcerative colitis, which can be a medical and surgical emergency in some cases, was challenging even before the pandemic. My colleagues in the UK should be proud of their health-care system, and should be congratulated for quickly adapting their practice patterns. In The Lancet Gastroenterology & Hepatology, Shaji Sebastian and colleagues² showed that adverse effects of the COVID-19 pandemic on the care and outcomes of patients with acute severe ulcerative colitis can be successfully contained.

IBD health-care providers have been forced by the initial waves of the COVID-19 pandemic to devise timely and effective ways to deliver care without compromising the safety of patients or themselves. Societal guidelines are based on case series, surveys, or expert opinions,3, 4, 5 resulting in discrepancies in real-world clinical practice. For example, the guidelines recommended the continuation of IBD medications in those without COVID-19 symptoms,3, 4, 5 but in a web registry-based study, a third of patients discontinued IBD medications, particularly anti-tumour necrosis factor agents and immunomodulators.⁶ Sebastian and colleagues² provide multicentre, case-control data for consecutive patients with acute severe ulcerative colitis during the COVID-19 pandemic. Compared with the pre-pandemic period, the health-care system and providers in the UK were able to deliver rescue therapy in a shorter time, despite the fact that patients more often required rescue medical (including the use of intravenous steroids, biologicals, ciclosporin, or tofacitinib) or surgical therapy. Therefore, clinical outcomes, comprising the response to rescue therapy, the requirement for colectomy or diverting ileostomy, the length of hospital stay, intensive care unit admission, postoperative complications, and outcomes at 3-month follow-up were similar between the pandemic and pre-pandemic periods. Less than 2% of patients in this study developed COVID-19.² These outcomes probably resulted from the efficiency of the health-care system and quick adaptation of practice through shifting to ambulatory pathways, timely administration of rescue therapy, and multidisciplinary approaches. However, more frequent use of medical or surgical rescue therapy during the pandemic suggests that the patients might have been more sick or taken longer to seek care, possibly stemming from logistical and accessibility barriers to medical, endoscopic, surgical, or ancillary services7, 8 or safety concerns.⁹ This gap must be bridged during the next phase of the pandemic.

The COVID-19 pandemic is far from over. It continues to be a threat to patients with acute severe ulcerative colitis and the general population, posing an ever-growing risk to our global health-care system. Although we remain hopeful for the eventual alteration of the disease course through vaccination, our understanding of COVID-19 is still evolving. Learning from reactive experiences and lessons of Sebastian and colleagues² is a valuable step for us to proactively develop an effective strategy and care path for the management of patients with acute severe ulcerative colitis in the next phase and aftermath of the pandemic.