Q&A: What GIs need to know about COVID-19
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As the concern about COVID-19 continues to spread, the entire medical community is on alert. Associations are cancelling or altering plans for scientific conferences, and institutions are implementing travel bans for faculty.
In gastroenterology, two recent studies have shown that patients with the disease may exhibit GI symptoms, and it may have the potential to spread through fecal-oral transmission.
But what do practicing GIs need to know? What should they tell their patients, particularly those with inflammatory bowel disease who might be immunosuppressed?
Healio Gastroenterology and Liver Disease talked with our Chief Medical Editor, Edward V. Loftus, MD, from Mayo Clinic in Rochester, Minnesota, about COVID-19 and what the GI community needs to do to address the growing panic. – by Alex Young
Healio: How should GIs be addressing the topic of coronavirus with their patients?
Loftus: Late last week and this past weekend were kind of a tipping point, and I anticipate we’re going to start getting a ton of calls on this. We’re going to need to have clear and consistent messaging for those patients. We have to confer with our colleagues in the near future to make sure were sending the right messages.
Now that the novel coronavirus is here in the United States, we need to move beyond containment to mitigation. For patients with underlying lung or other significant comorbidities, the risk for contracting serious illness is going to be higher than the younger IBD patient without comorbidities on therapy in remission. Their risk is probably lower.
We don’t want people to stop their IBD meds, because exacerbation of Crohn’s or UC is a real risk. The last thing a patient needs right now is to have a flare and end up in a hospital filled with patients with COVID-19. It’s better for that IBD patient to stay on their meds and do all the things that experts are recommending, like washing your hands frequently, avoiding touching your face, and practicing some social distancing. This would include stop shaking hands with people, don’t go places with large crowds, and avoid non-essential travel.
Healio: Is there a significant risk for infection among patients receiving TNF inhibitors?
Loftus: We don’t know yet if there’s a differential risk for the different drugs, but if I had to guess, it would be that corticosteroids have the potential for the highest risk of increasing susceptibility. If patients are on steroids, they might want to taper those. The next level of concern would be the conventional immunosuppressants, such as azathioprine or methotrexate. The biologics are probably okay.
Healio: How does risk for coronavirus infection compare with more common viruses (like influenza) among this vulnerable patient population?
Loftus: It’s probably geographic. The U.S. hotspots as of March 11, seem to be Seattle, the San Francisco Bay Area, New York, and Boston. For IBD patients outside these areas, the risk is low, but the situation is rapidly evolving. There’s a bit of underlying panic going on, but if patients follow some of these sensible guidelines, their risk is going to be pretty manageable.
Healio: If exposure occurs among a patient receiving TNF inhibitors, is there anything that can be done to curtail infection?
Loftus: We don’t have enough data at this time. There’s been speculation that the virus interacts with the angiotensin-converting-enzyme, which can be found in the lungs. Some people think that patients on ACE inhibitors are going to do better than people who aren’t, but it’s purely speculative at this time. We don’t have hard clinical data that show we can do anything with that.
Healio: Anything the practicing GI needs to know?
Loftus: People have been bandying about the idea of a global registry, and people are talking about using some kind of database where physicians can enter in data to track IBD patients who develop COVID-19 to see if there are any issues. I am on an email chain of over 50 physicians from multiple countries, and nobody is aware of any IBD patient who has contracted COVID-19. It’s not scientific, but nobody is aware of such a case. Which is kind reassuring, but doesn’t exclude the possibility that it could become an issue.
Healio: How do you handle the panic?
Loftus: There are probably a lot of people out there who are anxious about this and blocking up the health system by coming in and demanding to be tested when they basically have a cold. I don’t know how you address that. It’s a fine balance, but I believe if you give people more information, they are able to process the whole situation better.
I suspect that’s what is going to happen. Once this shakes out, I think the mortality rate will ultimately be lower than expected, and it will also be age related. The typical IBD patient — people in their 20s, 30s, or 40s — their risk for mortality is low. The infirm, the elderly and patients with comorbidities are going to have the higher risk.
But what are the unintended consequences? It could mean more sick calls for health staff. We’re going to have to get used to being shorthanded at times. Hopefully we can keep this under control.
Perspective
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Jean-Paul Achkar, MD
In this rapidly evolving topic, studies related to SARS COVID-2 and the gastrointestinal (GI) tract are now being published. We know that the virus binds to ACE-2 receptors which are present on intestinal epithelial cells and leads to the concern for GI tract involvement with this virus. In particular SARS COVID-2 seems to have a much higher affinity for this receptor compared with the original SARS coronavirus. There have been a couple of studies that show that the RNA of the virus can be detected in stool of patients infected with COVID-19 disease. The significance of that is not clear because bile acids present in the intestinal juices might inactivate the virus. However, there was a new study that was able to detect live virus in the stool in a small number of patients. All this has brought up the concern for gastrointestinal infection and possible transmission of the virus via fecal route. In a Chinese study of 204 patients with COVID-19 infection, 48.5% of them complained of digestive symptoms with diarrhea as a symptom in 29% of cases.
Based on such studies, there are now multi-society guidelines recommending cancellation of elective endoscopic procedures and wearing appropriate personal protective equipment when performing endoscopy in COVID-19 positive patients.
From an IBD standpoint, patients on immunosuppressants or biologics should continue to take their medications (in accordance with their health care provider) because of the concern for a high risk of developing a disease flare. In particular, we should try to avoid using steroids in our IBD patients. We do not have much information about anti-TNF inhibitors but at this point we should continue those treatments for patients.
With information regarding this virus rapidly increasing, I agreed with the recommendations by Dr. Loftus.
Cleveland Clinic
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