Objective
Management of acute severe ulcerative colitis (ASUC) during the novel coronavirus
2019 (COVID-19) pandemic presents significant dilemmas. We aimed to provide
COVID-19-specific guidance using current British Society of Gastroenterology (BSG)
guidelines as a reference point.
Design
We convened a RAND appropriateness panel comprising 14 gastroenterologists and
an IBD nurse consultant supplemented by surgical and COVID-19 experts. Panellists
rated the appropriateness of interventions for ASUC in the context of severe acute
respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Median scores and
disagreement index (DI) were calculated. Results were discussed at a moderated
meeting prior to a second survey.
Results
Panellists recommended that patients with ASUC should be isolated throughout their
hospital stay and should have a SARS-CoV-2 swab performed on admission. Patients
with a positive swab should be discussed with COVID-19 specialists.
As per BSG guidance, intravenous hydrocortisone was considered appropriate as
initial management; only in patients with COVID-19 pneumonia was their use deemed
uncertain. In patients requiring rescue therapy, infliximab with continuing steroids
was recommended. Delaying colectomy because of COVID-19 was deemed
inappropriate.
Steroid tapering as per BSG guidance, was deemed appropriate for all patients apart
from those with COVID-19 pneumonia in whom a 4-6-week taper was preferred. Post-ASUC maintenance therapy was dependent on SARS-CoV-2 status but, in general,
biologics were more likely to be deemed appropriate than azathioprine or tofacitinib.
Panellists deemed prophylactic anticoagulation post-discharge to be appropriate in
patients with a positive SARS-CoV-2 swab.
Conclusion
We have suggested COVID-19-specific adaptations to the BSG ASUC guideline using a
RAND Panel.