TNF antagonists safe for IBD patients with COVID-19

The use of tumour necrosis factor (TNF) antagonists does not lead to a worse prognosis in patients with coronavirus disease 2019 (COVID-19), according to a new study. Systemic corticosteroids, on the other hand, appear to be a significant risk factor for severe disease.

“Given the expanding knowledge that persons with comorbidities are disproportionately affected by COVID-19, there is an urgent need to evaluate this emerging infection on patients with systemic, autoinflammatory conditions such as inflammatory bowel disease (IBD), many of whom are treated with immunosuppressive medications,” researchers said.

Of the 525 enrolled COVID-19 patients (median age, 41 years; 52.6 percent male) with IBD, most had Crohn’s disease (59.4 percent), and IBD was in remission in 58.9 percent. Almost half (43.4 percent) of the participants were on TNF antagonist medication, and majority (63.4 percent) had no other comorbidity outside IBD. [Gastroenterology 2020;159:481-491.e3]

Thirty-one percent of the patients needed to be hospitalized, and five percent were admitted to intensive care unit (ICU). Twenty-one required mechanical ventilation, and 16 died. The primary outcome of a composite of death, need for ventilation, and ICU admission was reported in 37 patients, yielding a rate of 7 percent.

Older patients sustained worse outcomes than their younger counterparts. All cases of the primary outcome were in patients ≥60 years of age, and none occurred in paediatric participants. Only three youths (aged <20 years) had to be admitted, and none needed ventilation or intensive care. Nine patients on systemic corticosteroids also developed the composite outcome.

Multivariable analyses confirmed these interactions. For instance, increasing age carried a significantly greater risk of the primary outcome (adjust odds ratio [OR], 1.04, 95 percent confidence interval [CI], 1.01–1.06), as did having two or more comorbidities (adjusted OR, 2.9, 95 percent CI, 1.1–7.8).

Notably, the use of systemic corticosteroids (adjusted OR, 6.9, 95 percent CI, 2.3–20.5) and 5-aminosalicylate (ASA)/sulfasalazine (adjusted OR, 3.1, 95 percent CI, 1.3–7.7) likewise significantly raised the likelihood of the primary outcome. No such effect was reported for the use of TNF antagonists (adjusted OR, 0.9, 95 percent CI, 0.4–2.2).

However, in subsequent exploratory analyses, TNF antagonist combination therapy, as opposed to monotherapy, increased the likelihood of hospitalization or death (adjusted OR, 5.0, 95 percent CI, 2.0–12.3).

“As TNF antagonists are the most commonly prescribed biologic therapy for patients with IBD, these initial findings should be reassuring to the large number of patients receiving TNF antagonist therapy and support their continued use during this current pandemic,” the researchers said.

“Furthermore, in a direct comparison, we observed that 5-ASA/sulfasalazine-treated patients fared worse than those treated with TNF inhibitors,” they added. “Although we cannot exclude unmeasured confounding, further exploration of biological mechanisms is warranted.”