Professor El-Omar has chosen Dr Peter Irving from the Department of Gastroenterology, Guy’s and Saint Thomas’ Hospitals NHS Trust, London and Dr Shahida Din from the Department of Gastroenterology, Western General Hospital, Edinburgh, UK, to do the next #GUTBlog.

The #GUTBlog focusses on the paper “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” published in Gut in October 2020.  Dr Din is the first author on this paper and Dr Irving is the senior author, who worked with a team of IBD specialists to produce this paper.

“The COVID-19 pandemic has created unprecedented challenges to healthcare around the globe. In addition, due to the sudden appearance of SARS-CoV-2 and the relative lack of experience with similar viruses on such a large scale, there have been many areas of  uncertainty about how best to manage not only the resultant disease, COVID-19, but also other medical conditions in the context of the pandemic.

Acute severe ulcerative colitis (ASUC) is one of the most serious complications of UC with an estimated fatality rate of 1%. The management of ASUC is largely driven by evidence-based protocols¹ which rely largely on the use of steroids in combination with rescue therapy and / or surgery where steroids fail, with care being conducted in an inpatient setting. The emergence of COVID-19 revealed concerns that the recommended treatment pathways might be circumvented due to theoretical risks of corticosteroids, immunomodulators and surgery during the pandemic. Shortly after the outbreak of SARS-CoV-2,  data collection was initiated in order to guide the management of IBD in the context of the pandemic including registries such as IBD-SECURE². However, such registries have many potential weaknesses, take time to report and were likely to include only a small number of patients with ASUC. There remained, therefore, a clear need for guidance to aid clinical decision making. The decision was made review the current BSG ASUC guideline¹ for managing ASUC to establish whether they should be adapted during the COVID-19 pandemic. In view of the lack of evidence and the short time frame, it would have been inappropriate to go through a formal guidelines process and, clearly, a different approach was needed.

The RAND methodology was designed to provide guidance in areas of uncertainty and, whilst originating from a military background, its use in healthcare to guide clinical decision making is well established, largely in situations where evidence is lacking.  Whilst, like all guidance, RAND panels cannot provide a solution for the infinite number of clinical scenarios that may be encountered, they provide a framework for grading the appropriateness of a specific intervention in defined circumstances. Unlike consensus panels, agreement is not sought, and uncertainty is an acceptable outcome. The process starts with the assembly of a panel of appropriate experts which, in this case, included not only IBD medical and surgical specialists but also respiratory physicians, intensivists and infectious disease experts. Next the available evidence was assimilated and reviewed before a questionnaire covering relevant clinical scenarios in ASUC was circulated to the voting members of the panel. The answers were anonymised and reviewed at a virtual panel meeting to allow areas of disagreement to be discussed, after which the scenarios were re-rated providing the results of the RAND panel.  This methodology has the advantage of being rapid and we were able to move from conception of the idea to online publication of the manuscript in a matter of weeks.

Largely the panel felt that deviating from the well-established pathways for managing ASUC was inappropriate. For example, use of ambulatory care for the provision of intravenous steroids was not accepted by the panel; whilst not all panel members had the same opinion, the median score (which drives the outcome) was in the ‘inappropriate’ range and the level of disagreement, as measured by the disagreement index, was below the threshold of 1. Similarly, in the vast majority of situations, sticking to standard treatment with intravenous hydrocortisone, using rescue therapy with infliximab where appropriate, and recommending colectomy for failed medical therapy was supported, the overwhelming view being that the threat of ASUC was greater than the threat of COVID-19. Only for those patients with established COVID-19 and ASUC was there uncertainty about following the usual guidelines, an outcome that was perhaps not altogether surprising.

The recommendations are not guidelines but rather an adaptation of the existing guidelines. They provide a foundation on which care for ASUC can be based during this, and possibly future, respiratory pandemics pending the evolution of more robust evidence. They also provide an opportunity for clinical teams to consider practical changes to their inpatient services and the support of the British Society of Gastroenterology is important in this regard.

Collaborative working during the COVID-19 pandemic has provided a model for the future and has shown how the sharing of limited clinical data can help to inform and define IBD care in difficult circumstances. This relies in part on the use of digital technology, and the step change in this field induced by the pandemic, not only in terms of academic collaboration but also in the fields of patient care and medical training, may be one of the positive outcomes that we see as a result of COVID-19.”

References

1. Christopher A. Lamb^{1, 2}*, Nicholas A. Kennedy^{3, 4}, T. R. et al.British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 68, s1–s106 (2019)
2. SECURE-IBD. SECURE-IBD Registry: Surveillance Epidemiology of Coronavirus (COVID-19) Under Research Exclusion. https://covidibd.org/updates-and-data/ (2020).