Editorial: the impact of COVID on management of IBD flares—different care but similar outcomes

The COVID19 pandemic brought about profound changes to the delivery of healthcare. These practice changes and their impact on clinical outcomes have been underinvestigated.1 This is particularly relevant to the care of patients with inflammatory bowel diseases (IBD), who often require frequent laboratory and intermittent structural monitoring.2 Saifuddin et al3 performed a retrospective observational cohort study evaluating 1864 patients with IBD from 60 UK National Health Service trusts who selfreported IBDrelated symptoms during the first 4 months of the COVID pandemic compared to patients reporting symptoms prior to the pandemic. Prescribing and monitoring patterns were assessed, as were 3month outcomes including steroidfree remission, hospital admission and management of flares. In a smaller cohort, they also examined the influence of presumed COVID19 infection on clinical outcomes in IBD. Prescribing patterns were modestly influenced by the pandemic. Among patients with Crohn's disease (CD), treatment with infliximab and thiopurines was reduced by 3% and 5%, respectively, while use of budesonide (4%) and vedolizumab (3%) increased. In ulcerative colitis (UC) and unclassified colitis, treatment with infliximab (2%), budesonide (3%), and tofacitinib (1%) increased. Modifications also occurred in biochemical and structural evaluations and were more consistent across IBD: in CD, there was an increase in faecal calprotectin (FC) use (10%), but reduced CRP use (8%), while rates of radiology and endoscopy remained the same. In UC, FC use (13%) and radiographic imaging (3%) increased and CRP (8%) and endoscopy decreased (16%). In the pandemic period, providers prescribed fewer systemic corticosteroids for disease exacerbations (CD: IV steroids: 13%, PO steroids: 11%; UC: IV steroids 13%, PO steroids 7%). Conversely, budesonide use increased (CD: 9%; UC: 7%). Additionally, ustekinumab use increased in CD (5%), as did vedolizumab in UC (3%). Patients in both groups were less likely to utilise emergency care (CD 11%; UC 10%) and less likely to be admitted (CD 20%; UC: 14%) during the pandemic. Longer term, 3month steroidfree remission rates in both CD and UC patients were unchanged. The authors also performed a limited analysis regarding presumed COVID19 infection and IBDrelated outcomes, noting that these individuals were less likely to be in steroidfree remission and more likely to be admitted. However, COVID19 cases were not confirmed via assay. Overall, these findings highlight increased indirect disease activity monitoring (i.e., increased FC use) and increased use of medications with favourable safety profiles, as well as reduced urgent and inpatient medical care during the pandemic. It is reassuring that, despite these changes, clinical outcomes for patients with IBD remained stable. This suggests that increasing the use of medications with favourable safety profiles and noninvasive monitoring may be possible more generally. It remains challenging, however, to exclude other reasons for these modifications, such as practice pattern changes or medication availability, particularly related to ustekinumab, which was approved for UC in the UK in June 2020. However, It will be important to study these practice variations within other populations to determine if these modifications might reduce therapeutic risks or healthcare utilisation in the broader IBD population.