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Inflammatory bowel disease (IBD) is a longstanding debilitating disease, which occurs due to complex interactions between genetic, environmental and inflammatory processes affecting the gut and other extra gastrointestinal systems. IBD includes Ulcerative Colitis (UC) and Crohn's Disease (CD), accompanied by frequent relapse and remissions. Facing the covid-19 pandemic has changed the current practice in IBD in terms of patient care and follow-up. Although, there is no current evidence that the SARS-CoV-2 virus exacerbates underlying IBD. In a recent meta-analysis of 24 studies, the risk of SARS-CoV-2 infection in IBD is found to be equivalent to that of the general population. However, when compared to CD, UC has a higher risk of negative adverse outcomes, especially on steroids. Discontinuing current medications for IBD such as 5- ASA, corticosteroids, immunomodulatory and biologic therapies due to various reasons may trigger disease flare, disability and dilemma to restart therapy. Steroids are effective non-selective anti-inflammatory, immunomodulatory, vasoconstrictive and anti-proliferative drugs. It is associated with several side effects even at modest dosages. Many studies have shown that a 5-year probability of receiving steroids is up to 75% in IBD patients. European Crohn's and Colitis Organization (ECCO) guidelines recommend combining corticosteroids with 5- ASA preparations as first-line therapy in mild to moderate UC flares and moderate to severe ileocecal colonic CD. The risk of severe infections, gastrointestinal bleed, osteoporosis, cushing syndrome, poor glycemic control, psychosis, sleep disturbances, hypertension and delayed SARS-CoV-2 virus clearance is amongst adverse steroid effects.

Self-medication is a major issue given the current pandemic situation, particularly in underdeveloped countries and having poor health infrastructure. Self-medication is defined by the World Health Organization (WHO) as "The selection and utilization of medications to treat self-recognized symptoms or ailments without consulting a physician” (9). Especially in IBD, the use of non-prescription drugs is common, notably corticosteroids, which are used by up to 15% of patients. According to a survey of 546 patients by Gismero et al., Selfmedication was more prevalent among IBD patients when treated by general practitioners than IBD specialists (p=0.007). Many studies have shown that having frequent disease flares, keeping the steroids after treatment completion, fear of symptom worsening, or to achieve quick symptom relief, preemptive prescription in case of flare by the primary care doctor, irregular follow-ups, electronic prescriptions, and ignorance of medications associated side effects were all factors related to self-medication behaviors. In our experience, 39 IBD (36 UC, 3 CD) patients were admitted between March 2020 to June 2021 at our center. The mean age of the study group was 39.6 ± 14.1 years, with a male predominance (56.4%). We retrospectively observed that 46.1% (18/39) of the patients had received at least one dose of corticosteroids prior to the current admission to our center. Of these, 17.9% (7/39) patients had a history of self-medication with steroids, and 28.2% (11/39) patients had a prescription of Steroids by nongastroenterologists [Table 1].

Table 1: Demographics and self-medication frequency with oral steroids.

Telemedicine services are a popular approach that has shown promising results in IBD care, especially in times of the covid-19 pandemic. Although telemedicine services may not be equivalent to that of standard referral center care. It is a cost-effective platform that can avoid unnecessary health centers visits, particularly with the current travel restrictions. Telemonitoring interventions from IBD health care providers in the form of weekly assessment of symptoms, medication reconciliation, side effect profile monitoring and specified action plans help monitor patients with active IBD symptoms. Further, Integrating multidisciplinary IBD services, digging up previous records, identifying patients who need close follow-up, and actively contacting them will also help understand the disease course and prognosis better. In addition, IBD-specific knowledge can also be delivered through online lectures, instructional messages in local languages, teleconferencing, web-based group discussions, and IBD specific applications. There is room for further development by exploring sophisticated virtual information delivery systems that are both affordable and accessible to the community. This provides the required attention and social support in patients with IBD, who often necessitate lifelong care.

In conclusion, IBD management is confronted with additional problems during the covid-19 pandemic. We identified a higher frequency of steroid self-medication (17.9%) and steroid overprescription (28.2%) by non-gastroenterologists. Use of Telemonitoring systems will positively influence patient-IBD care provider communication, curbing misinformation, disease monitoring, and improving drug compliance.