The effects of covid19 on IBD prescribing and service provision

Introduction: There are limited data on the effect of COVID19 on inflammatory bowel disease (IBD) service provision and prescribing practices Aims & Methods: We aimed to quantify the effects of COVID19 on our IBD service This included evaluation of service provision, prescribing practices and use of therapeutic drug monitoring (TDM) This is a single centre retrospective observational cohort study We extracted data from our local IBD databases, electronic patient records and radiology and endoscopy reporting systems between 16/3/20-17/4/20 and the corresponding period in 2019 To evaluate differences in prescribing practices we compared treatment decisions, made for patients with active disease in our biologic and immunosuppressant multidisciplinary meeting We then reviewed the characteristics of patients who had been commenced on, or had switched, biologic therapy To compare these cohorts we used Fisher's exact test for categorical data and Mann-Whitney test for continuous variables Descriptive statistics were used for prescribing practices and service provision Results: Amongst patients initiating IBD therapy, a higher proportion were commenced on biological therapy during COVID19 compared with prepandemic (29/45, 64% vs 19/50, 38%) We compared characteristics of patients commencing on or switching biologic therapy pre-COVID19 (n=37) and during COVID19 (n=36) The cohorts had similar IBD phenotypes, age of onset as well as disease extent/distribution In the pre-COVID19 cohort the median age was higher (36 vs 29 years, p=0 02) and median disease duration was longer (9 3 vs 5 2 years respectively, p=0 009) During COVID19 there was an increase in the proportion of patients receiving vedolizumab (22% vs 39%), adalimumab (19% vs 25%) and ustekinumab (24% vs 28%), while infliximab and tofacitinib prescribing fell (14% vs 3% and 8/37 vs 2/36 respectively) Across all biologic classes there was a reduction in concomitant immunomodulator prescribing and a tendency towards prescribing biologics in immunomodulator-naive patients New prescriptions of thiopurines for any indication fell by 96% (28 vs 1) During COVID19 there was a preference for vedolizumab or ustekinumab compared to the preceding year (24/36, 67% vs 17/37, 46%) and this cohort was more likely to be TNF-naive 18/24 (75%) vs 3/17 (18%) pre-pandemic Use of TDM fell by 75% during the pandemic (240 vs 59 tests pre- and during pandemic respectively) Values for thiopurine metabolites and anti- TNF levels pre- and during COVID19 were 143 vs 44 samples and 97 vs 15 samples respectively The number of patients seen in outpatient clinics was reduced by 68% Similarly, the number of MRI scans, lower gastrointestinal endoscopies or abdominal operations fell by 87%, 85% and 100% respectively Conversely, clinical nurse specialist and pharmacy helpline contacts increased by 76% and 300% respectively Conclusion: We observed prescribing differences during COVID19, bypassing the initiation of immunomodulators and/or anti-TNF therapy for active disease in favour of newer biologic agents, predominantly as monotherapy Judging by the difference in disease duration between the two cohorts, there appeared to be a shift to earlier prescription of biologics We also observed a rapid reorganisation of service provision that included a shift towards telemedicine and online solutions