Best Practices in the Management of IBD During COVID-19 - Episode 13
Miguel Regueiro, MD: In the last bit of time that we have, I’m going to go back to Doug and come back to probe it. We talked a lot about COVID-19 [coronavirus disease 2019]. We talked a lot about the different medicines. We went through the trials. If you are to say some take-home points for the physicians in the community or the APPs [advanced practice providers] out there listening to this, what are your take-home points about IBD [inflammatory bowel disease] in the COVID-19 era?
Douglas C. Wolf, MD: It’s a time that is calling us to do even better than we have in the past to evaluate our patients and to stay in communication with them, whether it’s virtual or other, but virtual communication really helps out, to optimize therapy. The whole concept of treat-to-target and fine-tuning therapy is more important than ever.
I know you are all world leaders in the area of optimization of therapy and therapeutic drug monitoring, but I use it routinely as other practitioners should do also in assessing whether patients are where they should be. It’s just as important as getting a CRP [C-reactive protein] test. It’s more important. An erythrocyte sedimentation rate test is still useful in my practice. I get calprotectin with everybody, and people are much more comfortable in 2020 with getting a stool test when you explain to them how important that is, especially in conjunction with a drug level of ustekinumab, infliximab, or adalimumab.
Fine-tuning our patients is so important, as is doing all this periodic testing, especially at turning points and midlevels. It is about how gastroenterologists can do this and optimize the care of their patients during this COVID-19 period, and that will help more than anything.
Miguel Regueiro, MD: It’s interesting. As I heard you summarize the take-home points during COVID-19, it’s what we do anyway, right? We want to stay connected to our patients. The difference is that we’re using more virtual care and telemedicine. We want to monitor our patients. It may be more remote now with faecal calprotectin. Finally, we still have this treat-to-target or optimization that we’ve all been talking about and the importance—especially in my opinion—in keeping patients in remission and not having them flare.
It may be that we’re going to learn with COVID-19 too that, in an inflamed bowel, the inflammation may play a role in the severity of COVID-19, so having people walk around with IBD in remission will have a better protection against COVID-19, or if they get COVID-19, it may be a less severe case. Jean-Fred, I’ll give you the final words on take-home points for the community physician or APP with COVID-19 and IBD.
Jean-Frederic Colombel, MD: First, we need to reassure our patients and tell them that it’s not because you have IBD that you have an increased risk of COVID-19. Of course, it is important to respect the general rules of masking and social distancing even more if you have risk factors, which are very well known and nonspecific to IBD: age, obesity, and comorbidities. Second, it is important to be certain your disease is under control. Being in remission is a protective factor as well. Thirdly, don’t stop your medications. Don’t stop your medication unless you are on steroids. It is very simple. If you’re on steroids, we should try to wean the patient off steroids so it’s remission without steroids. There is also a point about thiopurines that recently emerged: We should try to stop thiopurines and switch from a combination therapy to monotherapy with drug monitoring as well to be certain that the drug levels are not going down. This is a point and a question mark that patients will have, and I want to open this point: What about the vaccine? What will happen with the vaccine?
What we are currently looking at is the impact of IBD medication and antibodies because this is an interesting question as well. There was a paper showing that patients on anti-inflammatory anticytokine therapy had low levels of antibodies. This is not our experience, but we have launched a new international study, which is called ICARUS, with the Oxford International Group, to look at the progression of antibodies over time, what will happen to the antibodies, and what will happen in the era of vaccination, which is close I hope.
Miguel Regueiro, MD: Those areexcellent points. If I were to summarize 2 things you’ve said, the first is that we should not have our IBD patients stop their medicines because of COVID-19, but we should be treating them the way we did pre–COVID-19: limiting our use of steroids, which is something we all agree on. If we are using combination therapy, we’re probably trying to limit thiopurines anyway or use more proactive monitoring with an anti-TNF agent.
A point we didn’t make is that we’re finding that ustekinumab and vedolizumab have such low immunogenicity that they do not require combinations. They’re a monotherapy. I like the fact that you brought up the vaccinations. The vaccinations, obviously aside from all the political charge, will come, and they will hopefully be effective. What we don’t know is this: Is it going to be a live vaccine or an activated vaccine? Will it have multiple doses or 1 dose? Is it going to have some immune activating property? We don’t know.
When I’m talking to my patients, I’m going to want them to get the vaccine. That’s definite. Jean-Fred, you mentioned that the medicines they’re on for their immune system are going to somehow alter the immunization rate, and I think we have to stay tuned on that.
Jean-Frederic Colombel, MD: Don’t forget the flu shot at this time.
Miguel Regueiro, MD: I’m glad you brought that up. That was something I thought of earlier. In the world of COVID-19, it’s more important than ever to get the good old influenza vaccine, because this is not an illness we want to see, especially coming into this fall and winter.
Wonderful. I really want to thank both Dr Jean-Fred Colombel and Dr Douglas Wolf for joining me today. Thanks for the insightful, invigorating discussion, and thanks to our audience for watching this HCPLive® presentation. We hope that you all found the Peers & Perspectives® discussion to be useful and informative, especially as we all learned more about COVID-19 and the impact of COVID-19 on diseases. With that, I thank everybody. Hopefully 1 of these days, we’ll see everybody in person. Have a good day, good morning, and good night. Wherever you are in the world, enjoy it. Stay safe.
Transcript Edited for Clarity