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Inflammatory bowel disease
Original research
Adaptations to the British Society of Gastroenterology guidelines on the management of acute severe UC in the context of the COVID-19 pandemic: a RAND appropriateness panel
  1. Shahida Din1,2,
  2. Alexandra Kent3,4,
  3. Richard C Pollok5,6,
  4. Susanna Meade7,
  5. Nicholas A Kennedy8,9,
  6. Ian Arnott1,
  7. R Mark Beattie10,
  8. Felix Chua11,
  9. Rachel Cooney12,
  10. Robin J Dart13,
  11. James Galloway14,
  12. Daniel R Gaya15,
  13. Subrata Ghosh12,
  14. Mark Griffiths16,17,
  15. Laura Hancock18,
  16. Richard Hansen19,
  17. Ailsa Hart20,21,
  18. Christopher Andrew Lamb22,23,
  19. Charlie W Lees1,24,
  20. Jimmy K Limdi25,26,
  21. James O Lindsay27,
  22. Kamal Patel5,
  23. Nick Powell28,
  24. Charles D Murray13,
  25. Chris Probert29,
  26. Tim Raine30,
  27. Christian Selinger31,
  28. Shaji Sebastian32,33,
  29. Philip J Smith34,
  30. Phil Tozer20,
  31. Andrew Ustianowski35,
  32. Lisa Younge20,36,
  33. Mark A Samaan7,
  34. Peter M Irving7,37
  1. 1 Department of Gastroenterology, Western General Hospital, Edinburgh, UK
  2. 2 Gastroenterology and Hepatology Unit, University of Edinburgh, Edinburgh, UK
  3. 3 Department of Gastroenterology, King’s College Hospital NHS Foundation Trust, London, UK
  4. 4 Faculty of Life Sciences & Medicine, King's College London, London, UK
  5. 5 Department of Gastroenterology, St George's Healthcare NHS Trust, London, UK
  6. 6 Institute of Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK
  7. 7 Department of Gastroenterology, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
  8. 8 Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
  9. 9 Exeter IBD Research Group, University of Exeter, Exeter, UK
  10. 10 Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK
  11. 11 Interstitial Lung Disease Unit, Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
  12. 12 Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
  13. 13 Department of Gastroenterology, Royal Free Hospital, London, UK
  14. 14 Department of Rheumatology, King's College Hospital, London, UK
  15. 15 Gastroenterology Unit, Glasgow Royal Infirmary, Glasgow, UK
  16. 16 Peri-operative Medicine, Barts Health NHS Trust, London, UK
  17. 17 Faculty of Medicine, National Heart and Lung Institute, London, UK
  18. 18 Department of General Surgery, Manchester University NHS Foundation Trust, Manchester, UK
  19. 19 Paediatric Gastroenterology and Nutrition, Royal Hospital for Children, Glasgow, UK
  20. 20 IBD Unit, St Mark's Hospital, London, UK
  21. 21 Antigen Presentation Research Group, Imperial College London, London, UK
  22. 22 Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
  23. 23 Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
  24. 24 Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, UK
  25. 25 Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester, UK
  26. 26 Manchester Academic Health Science Centre, Manchester, UK
  27. 27 Department of Gastroenterology, Barts Health NHS Trust, London, UK
  28. 28 Division of Digestive Diseases, Imperial College London, London, UK
  29. 29 Gastroenterology Research Unit, Department of Cellular and Molecular Physiology, University of Liverpool Institute of Translational Medicine, Liverpool, UK
  30. 30 Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  31. 31 Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  32. 32 Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
  33. 33 Department of Immunuology and Inflammation, Hull York Medical School, Hull, Kingston upon Hull, UK
  34. 34 Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
  35. 35 Department of Infectious Disease, North Manchester General Hospital, Manchester, UK
  36. 36 Crohn's and Colitis UK, Saint Albans, UK
  37. 37 Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
  1. Correspondence to Dr Peter M Irving, Department of Gastroenterology, Guy's and Saint Thomas' Hospitals NHS Trust, London SE1 7EH, UK; peter.irving{at}gstt.nhs.uk

Abstract

Objective Management of acute severe UC (ASUC) during the novel 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 its 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 postdischarge 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.

  • ulcerative colitis
  • clinical decision making
  • IBD clinical
https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/gutjnl-2020-321927

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    Footnotes

    • SD, AK, RCP and SM are joint first authors.

    • Twitter @NA, @DrChrisLamb, @jklimdi

    • Correction notice This article has been corrected since it published Online First. ORCID ID's have been added, figure 1 replaced and text 'COVID swab' within tables replaced with 'SARS-CoV-2'

    • Contributors All authors approved the final version. Study concept and design: SD, AK, RCP, MAS, PMI. Development of questionnaire: SD, AK, RCP, SM, PMI, MAS, NK. Data analysis: PMI, MAS, SM. Interpretation of data and drafting of manuscript: SD, AK, RCP, SM, MAS, NK, PMI. Panellists, experts and moderators: SD, AK, RCP, SM, NK, JOL, CAL, JKL, CP, CS, SS, DRG, TR, RJD, AH, LY, CWL, IA, FC, JG, AU, MG, PT, LH, MAS, SM, PMI. Contributions to literature review and critical revision of the manuscript for important intellectual content: All authors.

    • Funding PMI is supported by a grant from the Medical Research Council [MR/T005564/1]

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.