Multicenter and population cohort studies suggest that patients with inflammatory bowel disease (IBD) are not at unique risk of contracting COVID-19 or experiencing worse outcomes, with the exception of a few risk factors such as corticosteroid use and combination therapy that appear tied to greater risk of hospitalization and mortality. The findings line up well with previous experience with infectious disease and are reassuring, but they also underscore the need to taper steroids and de-escalate from combination therapy, when possible.
“There is not a clear increased risk of getting COVID-19 among IBD patients compared to the general population, and that seems to hold even if you look at certain medication types, [even] if patients are on immunosuppressives like thiopurines or anti-TNF [anti–tumor necrosis factor] drugs,” Ryan C. Ungaro, MD, said in an interview. Dr. Ungaro, who is with the Icahn School of Medicine at Mount Sinai, New York, discussed IBD and COVID-19 risks at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
Dr. Ryan C. Ungaro
A systematic review showed that 0.3% of IBD patients contracted COVID-19 during study periods, compared with 0.2%-4.0% of the general population, and a matched-cohort analysis of a national Veterans Affairs database showed an infection prevalence of 0.23% among patients with IBD versus 0.20% among those without (P = .29). The analysis also showed use of anti-TNF therapies or thiopurines was not associated with an increased risk.
Studies show that patients with IBD in general do not appear to be at greater risk of severe disease outcomes such as hospitalization or 30-day mortality. For example, a U.S. national database study of more than 40 million patients compared 232 patients with IBD who were diagnosed with COVID-19 with 19,776 non-IBD patients and found that, after propensity matching, there were no significant association between IBD and worse outcomes (risk ratio, 0.93; 95% confidence interval, 0.68-1.27; P = .86) or hospitalizations (RR, 1.10; 95% CI, 0.74-1.40; P = .91)).
However, some risk factors could be red flags. Data from the international SECURE-IBD registry showed an association between combined endpoint of ICU, requiring a ventilator, or death and advanced age (adjusted odds ratio, 1.04; 95% CI, 1.01-1.06; P < .01) and two or more comorbidities (aOR, 2.87; 95% CI, 1.05-7.85; P < .04). More specifically to IBD, severe COVID-19 was associated with use of corticosteroids (aOR, 6.87; 95% CI, 2.30-20.51; P < .001). In terms of other therapies, another study found a similar effect with thiopurines (compared with TNF monotherapy; aOR, 4.08; 95% CI, 1.65-9.78; Bonferroni adjusted P = .008), and combined use of anti-TNF drugs and a thiopurine (compared with TNF monotherapy; aOR, 4.01; 95% CI, 1.73-9.61; Bonferroni adjusted P = .013), but anti-TNF therapies alone trended toward a protective effect (compared with no anti-TNF therapy; aOR, 0.69; Bonferroni adjusted P = .52). That study found no significant association between severe outcomes and anti-IL 12/23 (compared with anti-TNF monotherapy; aOR, 0.98; 95% CI, 0.12-8.06; P = .98) or anti-integrin biologics (compared with anti-TNF monotherapy; aOR, 2.42; 95% CI, 0.59-9.96; P = .22).
Overall, the data are “generally consistent with prior data on infections and IBD: That steroids and combination therapy increase the risk of infection and bad outcomes and that interestingly biologic monotherapy may actually confer a little bit of protection against emergent outcomes and at a minimum appears to be neutral,” said Dr. Ungaro.
He noted that the recommendations from the IOIBD COVID-19 Task Force were based on expert opinion, but the new data have largely supported them overall. He did suggest some potential modifications, including reducing thiopurine use among patients on combination therapy. According to Dr. Ungaro, the recommendations do call for withholding all IBD therapy for 10 days after positive SARS-CoV-2 tests, whether the patient is symptomatic or not. “I think the recent data is reassuring that potentially in asymptomatic and maybe even mild cases, the monotherapy biologics – we can consider not delaying administering those. I think we need more data about that, but it’s reassuring that patients on those had no worse outcomes and [in fact did] slightly better,” Dr. Ungaro said during the presentation.
The data reinforced the need to consider tapering patients off corticosteroids or combination therapies, if possible. “It’s something we were doing in regular IBD care beforehand, but the COVID-19 pandemic offers another reason to limit the use of steroids and evaluate if patients are able to de-escalate from combination therapies,” said Dr. Ungaro.
On the other hand, there was concern among some patients early in the pandemic that their immunotherapy drugs may put them at risk of contracting COVID-19, which led some to discontinue medications. Ongoing studies are illustrating the problem with this, according to David T. Rubin, MD, professor of medicine at the University of Chicago and chair of the congress’s organizing committee. “The data do not in general suggest you should do that to protect yourself. In fact, being on the therapies may have a better outcome. Patients always want to come off their therapies, [but] during the pandemic that is a risk not worth taking. Getting sick from your Crohn’s disease or colitis, when there are limited health care resources and, in some places, limited hospital beds and where the rescue therapy might include steroids, is a risky proposition. It’s not the time to do this,” said Dr. Rubin.
Dr. David T. Rubin
With respect to vaccines, it appears so far that there is no increased risk of adverse events associated with IBD. Patients who are on immunosuppressive drugs may experience a lower response to immunization, which has been seen with other vaccines. “The benefits likely outweigh the risks based on our prior experience with other vaccinations. It’s an area of ongoing study, but I do think we should recommend that our IBD patients get the COVID-19 vaccine, especially if they have risk factors for severe disease,” said Dr. Ungaro.
Dr. Ungaro is on the advisory board for Bristol-Myers Squibb, Janssen, Pfizer, and Takeda. He has received funding from AbbVie, Boehringer Ingelheim, Eli Lilly, and Pfizer. He has been a speaker or received consulting fees from AbbVie and Eli Lilly. Dr. Rubin is a consultant for Janssen, Pfizer, Takeda, and AbbVie.
This article was updated Jan. 27, 2021.