LETTER TO THE EDITOR Management of inflammatory bowel diseases in the wake of COVID-19 pandemic To the Editor, The COVID-19 outbreak that started in December 2019 from China has developed into one of the greatest global health crisis of 21st century. As of 27th March 2020, more than half a million cases have been diagnosed worldwide with >26 000 deaths due to this pandemic. 1 Among gastroenterologists who manage patients suffering from inflammatory bowel diseases (IBD), there is con- cern regarding their ongoing immunosuppressive therapies which could render them more susceptible to acquire COVID-19 infec- tion and develop complications like acute respiratory distress syn- drome (ARDS). Previous literature, plagued with inconsistencies and conflicting evidence, have estimated the risk of infections with IBD pharma- cotherapy between 0.5% and 30%. 2 A study of 2600 IBD patients indicated that active disease and use of thiopurines were indepen- dent risk factors for serious viral infections. 3 Meta-analyses for different biologics used in IBD have failed to report a significantly greater risk of infection for most of them, although the data mostly comes from RCTs. 4,5 Despite minimal evidence, during the H1N1 influenza pandemic of 2009, experts had then agreed to temporarily withhold immuno- modulators in IBD patients with flu-like symptoms. 6 Given the lack of data on COVID-19 infections, stopping immunosuppres- sants in symptomatic patients seems to be a reasonable strategy; however, it carries the risk of causing a disease flare. One study re- ported disease relapse rate of 27% within first year after TNFα- inhibitor discontinuation. 2 Patients who develop disease flares may require higher doses of immunosuppressants to achieve con- trol and may even require hospitalization and/or endoscopic eval- uation. The SARS-CoV-2 virus has shown rapid transmission in health-care facilities where other infected individuals arrive for their care and even asymptomatic carries could transmit the dis- ease. Those with an IBD flare who visit such institutions could get exposed to the virus and theoretically could be at a higher risk of developing COVID-19 (Table 1). The SARS-CoV-2 virus has been detected in GI endoscopic bi- opsies and stool specimens, suggesting a risk of oro-fecal transmission. 7 This risk could perhaps be increased among in- fected patients who also have an IBD flare where constant diarrhea could shed millions of viral particles. Performing endoscopies on such individuals poses a threat of transmission to health-care per- sonnel who could infect other patients. As the COVID-19 pan- demic continues to spread, greater health-care resources are being channeled to minimize transmission. Strategies to minimize exposure to SARS-CoV-2 virus among IBD patients: 1 Counseling regarding frequent hand washing; social dis- tancing; and avoid touching eyes, nose, or mouth; 2 Conducting clinics via telehealth to minimize physical ex- posure; and 3 Continuation of appropriate therapy to minimize flares; this has been recommended by multiple GI societies in the United States. Syed Bilal Pasha, * Huda Fatima † and Yezaz A Ghouri ‡ Departments of * Medicine, ‡ Medicine-Division of Gastroenterology and Hepatology, University of Missouri-School of Medicine at Columbia, Columbia, Missouri, USA; and † Dow Medical College, Karachi, Pakistan References 1 WHO. Coronavirus disease (COVID-19) pandemic 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus- 2019. 2 Wheat CL, Ko CW, Clark-Snustad K, Grembowski D, Thornton TA, Devine B. Inflammatory bowel disease (IBD) pharmacotherapy and the risk of serious infection: a systematic review and network meta-analysis. BMC Gastroenterol. 2017; 17: 52 PubMed PMID: 28407755. Pubmed Central PMCID: PMC5391579. Epub 2017/04/15. eng. 3 Danese S, Cecconi M, Spinelli A. Management of IBD during the COVID-19 outbreak: resetting clinical priorities. Nat. Rev. Gastroenterol. Hepatol. 2020 2020/03/25. 4 Singh S, Fumery M, Sandborn WJ, Murad MH. Systematic review with network meta-analysis: first- and second-line pharmacotherapy for moderate-severe ulcerative colitis. Aliment. Pharmacol. Ther. 2018; 47: 162–75 PubMed PMID: 29205406. Epub 2017/12/06. eng. Table 1 Risk of infection with biologics during maintenance therapy for inflammatory bowel diseases, compared to placebo 4,5 Drug OR (95% CI) Crohn’s disease Infliximab 0.84 (0.55–1.27) Adalimumab 1.49 (1.07–1.27) Certolizumab 3.00 (0.60–15.03) Vedolizumab 1.13 (0.72–1.77) Ustekinumab 0.94 (0.58–1.52) Ulcerative colitis Infliximab 1.30 (0.92–1.83) Adalimumab 1.23 (0.91–1.65) Golimumab 1.85 (1.20–2.86) Vedolizumab 1.03 (0.60–1.79) Tofacitinib 1.75 (1.13–2.70) doi:10.1111/jgh.15056 1 Journal of Gastroenterology and Hepatology •• (2020) ••–•• © 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd