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

Din, Shahida; Kent, Alexandra; Pollok, Richard C; Meade, Susanna; Kennedy, Nicholas A; Arnott, Ian; Beattie, R Mark; Chua, Felix; Cooney, Rachel; Dart, Robin J; Galloway, James; Gaya, Daniel R; Ghosh, Subrata; Griffiths, Mark; Hancock, Laura; Hansen, Richard; Hart, Ailsa; Lamb, Christopher Andrew; Lees, Charlie W; Limdi, Jimmy K; Lindsay, James O; Patel, Kamal; Powell, Nick; Murray, Charles D; Probert, Chris; Raine, Tim; Selinger, Christian; Sebastian, Shaji; Smith, Philip J; Tozer, Phil; Ustianowski, Andrew; Younge, Lisa; Samaan, Mark A; Irving, Peter M

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.