Clinical Pearl: COVID-19 and IBD
Coronavirus disease 2019 (COVID-19) has significantly affected the care of our patients. As we are learning about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its impact in patients with inflammatory bowel disease (IBD), several questions have come up. Are patients with IBD at increased risk of SARS-CoV-2 infection? How does COVID-19 present in these patients, and are they at increased risk of complications?
Are patients with IBD at increased risk of COVID-19?
There is currently no evidence that patients with IBD are at increased risk of SARS-CoV-2 infection.(1) Similar infection rates in patients with and without IBD have been reported in studies out of the US, Europe and Asia.(2-5) In particular, anti-tumor necrosis factor (anti-TNF) agents and thiopurines have not been found to increase the risk of COVID-19.(2)
However, in a study out of NYC, although patients with IBD were not at increased risk of infection overall, moderate to severe disease activity and corticosteroids were associated with increased rates of SARS-CoV-2 infection among patients with IBD.(6)
How does COVID-19 affect patients with IBD and their care?
COVID-19 may present differently in patients with IBD.(1) Patients with IBD who develop SARS-CoV-2 infection have symptoms of abdominal pain and diarrhea more frequently than patients without IBD.(6, 7) COVID-19 may also mimic disease flares.(1, 6) Among patients with IBD, COVID-19 is not only associated with increased rates of GI symptoms, but also an increased risk of elevated inflammatory markers and endoscopically active disease compared to patients without COVID-19.(6) Of note, fecal calprotectin as well can be increased in the setting of COVID-19 diarrhea, even in patients without IBD.(8)
The COVID-19 pandemic itself has also had a significant impact on the care of patients with IBD.(9) In addition to a change in the delivery of care with a transition to telemedicine and reduced access to endoscopy,(9) non-adherence to infusible biologics has increased by 70%.(10) In a nationwide VA cohort, up to a quarter of patients were found to have intervals of more than 10 weeks between infusions.(10)
Do patients with IBD have worse outcomes with COVID-19?
Several studies have assessed COVID-19 outcomes among patients with IBD,(11) including the Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD) registry.(12) This international collaborative effort has helped gather data on 2,156 patients with IBD and COVID-19 as of August 25, 2020.(12) According to available data thus far, COVID-19 does not seem to be associated with worse outcomes in patients with IBD.(13-16) In particular, biologics have not been associated with an increased risk of COVID-19 complications in several studies, including in an analysis of the first 525 cases of the SECURE-IBD registry.(13-15)
In fact, biologics including janus kinase (JAK) inhibitors and anti-TNFs (e.g. infliximab, adalimumab) are being evaluated as possible therapies for COVID-19 in clinical trials.(17) In addition, 2 case reports have described the use of infliximab to treat both severe IBD and COVID-19 with promising results.(18, 19)
Risk factors for severe COVID-19
Although patients with IBD are not at increased risk of COVID-19 complications compared with the general population, several risk factors have been associated with more severe outcomes in IBD.(13, 14) Data from the SECURE-IBD registry have found corticosteroid use, the presence of 2 or more comorbidities, and older age to be associated with more severe COVID-19.(20) Although 5-aminosalicylate (5-ASA) was also found to be a risk factor, it is currently unclear whether this is due to confounding or a true association.(13) Additionally, an Italian study found active disease to be associated with worse outcomes in patients with IBD, including increased rates of hospitalization and death.(14)
Managing IBD in the setting of COVID-19
Several societies have proposed detailed recommendations for the management of patients with IBD in the setting of SARS-CoV-2 infection, including the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the British Society of Gastroenterology (BSG) and others.(21-23) Given the limited data available, most of these recommendations are based on expert opinion and are subject to change as we are learning more about COVID-19 and its impact on IBD.
If not infected with SARS-CoV-2, patients are generally recommended to continue IBD therapies except for corticosteroids, which should preferably be tapered or stopped.(21, 22)
In the case of SARS-CoV-2 infection, current guidance recommends to hold immunosuppressive medications until resolution of COVID-19 (at least 10 days after symptom onset and at least 3 days after recovery according to IOIBD recommendations).(21, 22, 24) A detailed list of recommendations on several aspects of management can be found on the IOIBD website.(25)
Patients with IBD do not appear to be at increased risk of SARS-CoV-2 infection. However, corticosteroid use and active disease may increase the risk of COVID-19 in this setting. In addition, although patients with IBD have similar COVID-19 outcomes compared with the general population, several risk factors for severe COVID-19 have been identified and include corticosteroid use, older age, comorbidities, active IBD and possibly 5-ASA use. Several societies have proposed expert recommendations to help guide the management of patients with IBD in the context of COVID-19. These may change as we are learning more about SARS-CoV-2 and how it affects patients with IBD. Clinicians are encouraged to report all cases of COVID-19 in their patients with IBD to the SECURE-IBD registry in order to help improve our understanding of COVID-19 and its impact on our patients.