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Pandemic drives adaptations to management guidelines for acute colitis in kids

Reuters Health - 11/09/2020 - The management of pediatric acute severe colitis (ASC) might need to be altered in the context of the COVID-19 pandemic, according to a RAND appropriateness panel.

The European Crohn's and Colitis Organization/European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ECCO/ESPGHAN) guidelines rely heavily on immunosuppression and the potential for surgery for managing pediatric ASC. The potential risks of these interventions need to be considered in light of the ongoing pandemic.

Dr. Jochen Kammermeier of Evelina London Children's Hospital, in London, and colleagues evaluated the appropriateness of interventions by considering 113 clinical scenarios, of which they initially rated 30 as appropriate, 22 as uncertain and 61 as inappropriate.

They agreed that all patients admitted to hospital with ASC should be tested for SARS-CoV-2 on admission, with repeat testing at the point of requiring rescue therapy and/or surgery. Irrespective of testing results, these patients should be isolated throughout their admission.

All patients with a positive SARS-CoV-2 test should be referred to a COVID-19 specialist, irrespective of the presence of symptoms or signs of COVID-19 infection.

Inpatient intravenous methylprednisolone was the only first-line treatment deemed appropriate for the initial management of patients presenting with ASC, with all other agents (infliximab, cyclosporine, and tacrolimus) deemed inappropriate, irrespective of SARS-CoV-2 status.

Delaying colectomy was considered inappropriate in those who require it, irrespective of COVID-19 status, according to the new recommendations, published in Gut.

For patients with a pediatric ulcerative colitis activity index (PUCAI) >65, the panelists recommended following the standard guideline by initiating infliximab and continuing corticosteroids as rescue therapy, whereas concurrent cyclosporine treatment was deemed uncertain and the use of tacrolimus was deemed inappropriate.

Second-line immunosuppressive therapy with simultaneous discontinuation of intravenous corticosteroid therapy was deemed inappropriate, irrespective of SARS-CoV-2 status, as was management by colectomy after failed first-line therapy (unless complications indicating the need for surgery were present).

Prophylactic anticoagulation for all patients was recommended during the hospitalization, but not after discharge for those who tested negative for SARS-CoV-2. Ongoing prophylactic anticoagulation was deemed uncertain for those who tested positive.

"Our recommendations have the potential to increase clinician confidence and may be of considerable benefit as new challenges occur during the continued pandemic," the authors conclude.

Dr. Claudio Romano of the University of Messina, in Italy, who participated in the development of the ECCO/ESPGHAN guidelines but was not involved in the pandemic adaptation, told Reuters Health by email, "This document is extremely important and adapts the ESPGHAN recommendations in time COVID-19 pandemic. It is important to underline the message that treatment with steroids can be started early in severe acute colitis regardless of SARS-CoV-2 positivity."

"The most important message is that in the child with severe acute colitis, in case of failure of rescue therapy, the surgery must never be delayed," he said.

Dr. Kammermeier did not respond to a request for comments.

By Will Boggs MD

SOURCE: https://bit.ly/32i5GNc Gut, online September 1, 2020.

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