IBD and COVID-19: Who Is at Risk?

Factors that were associated with a severe course of COVID-19 among patients with inflammatory bowel disease (IBD) included older age, the presence of comorbidities, and treatment with corticosteroids.

IBD patients older than 60 who developed COVID-19 had an odds ratio of 1.04 (95% CI 1.01-1.06, P=0.002) for a composite endpoint of admission to the intensive care unit (ICU), mechanical ventilation, or death, reported Michael Kappelman, MD, of the University of North Carolina at Chapel Hill, at the Advances in Inflammatory Bowel Diseases virtual meeting.

In addition, for those with two or more comorbidities, the odds ratio for that composite endpoint was 2.87 (95% CI 1.05-7.85, P=0.04) compared with patients with no comorbidities. Among those receiving systemic corticosteroids, the odds ratio was 6.87 (95% CI 2.30-20.51, P<0.001).

These findings emerged from analyses of the Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD) database, which is an international voluntary reporting system for COVID-19 among patients with IBD. Cases are reported to the database by IBD providers, including information on geographic location, demographics, IBD characteristics and treatments, comorbidities, and COVID-19 outcomes.

Overall, by the end of November, 3,493 cases had been reported from 62 countries and 47 U.S. states. Patients’ mean age was 40, 50% were women, and 57% had Crohn’s disease. Of these patients, 21% were hospitalized with a mean length of stay of 10.2 days, 4% required ICU treatment, and 2% died.

“An important question has been when patients with IBD develop COVID-19, is it more severe?” said Kappelman. He and his colleagues recently published data from the first 525 cases included in SECURE-IBD, reporting that the age-standardized mortality ratios for their cohort compared with population-based rates in China, Italy, and the U.S., respectively, were 1.8 (95% CI 0.9-2.6), 1.5 (95% CI 0.7-2.2), and 1.7 (95% CI 0.9-2.5), with confidence intervals that crossed 1. “However, several months later with an additional 2,000 cases the confidence intervals no longer crossed 1,” he said.

“Patients with IBD may have a more severe course than the general population, but not by much, and taken together, my belief is that available data are actually more reassuring than alarming,” he stated.

In discussing the effects of age on adverse outcomes, he noted that the majority of patients who died were older than 60. The fatality rate in SECURE-IBD for patients ages 60-69 was 5.6%, rising to 8.3% for those ages 70-79 and to 26.1% for those 80 and older.

Conversely, there have been no deaths among patients ages 18 years and under. In that age group, only 7% were hospitalized and only two individual patients required mechanical ventilation.

With regard to the potential impact of immunosuppressive medications on COVID severity and outcomes, he explained that tumor necrosis factor (TNF) inhibitors actually appeared to be protective, with an odds ratio for the composite endpoint of ICU/ventilation/death of 0.9 (95% CI 0.37-2.17), which is similar to what has been observed in the rheumatoid arthritis community.

In addition, when combination therapy with a thiopurine or a thiopurine alone were compared with anti-TNF treatment, there was a fourfold increased risk of ICU/ventilation/death.

Another observation in the SECURE-IBD cohort is that approximately one-quarter of patients developed new symptoms with COVID-19, most often diarrhea and abdominal pain, so clinicians should be suspicious of COVID-19 in IBD patients who develop new symptoms.

In conclusion, Kappelman explained his way of tailoring treatment based on the emerging COVID data:

“Treatment of IBD has always involved balancing benefits and harms of treatment and the disease itself. COVID plays a minor role in my balancing the benefits and risks, with the corollary that IBD should play a minor role in decisions about returning to work, school, etc.,” he said.