What COVID-19 means for IBD care

Updates from the SECURE-IBD* registry reveal that treatment with thiopurine, either alone or in combination with tumour necrosis factor inhibitors (TNFis), for inflammatory bowel disease (IBD) was associated with a greater risk of severe COVID-19 compared with TNFis monotherapy. 

However, experts said this does not mean practice should be changed for IBD management in times of COVID-19 outbreak.  

“The treatment of IBD has always involved balancing benefits and harms of treatment and of the disease itself,” said Dr Michael Kappelman of the University of North Carolina at Chapel Hill, North Carolina, US, who presented the study during the AIBD 2020 Conference.

“COVID-19 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 [or] school,” he added.

Previous analysis of the SECURE-IBD data has shown that use of systemic corticosteroids presents a risk factor for severe COVID-19 illness among patients with IBD (adjusted odds ratio [aOR], 6.87; p<0.001).

In addition, both older age (aOR, 1.04; p=0.002) and having ≥2 comorbidities (aOR, 2.87; p=0.04) were also associated with severe COVID-19 in these patients.

“An important question has been when patients with IBD develop COVID-19, is it more severe?” raised Kappelman. “[They] 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.”

Diving deeper into the SECURE-IBD data, Kappelman presented updates on the potential impact of IBD medications on COVID-19 severity.

The researchers found that TNFis appeared to be protective against the development of severe COVID-19 — defined by the composite outcomes of ICU admission, mechanical ventilation, or death (aOR, 0.90; p=0.81). [AIBD 2020, session VIII]

Conversely, treatment with thiopurine, either alone or in combination with TNFi, was associated with a fourfold increased risk of severe COVID-19 compared with TNFi monotherapy (aOR, 4.08; 95 percent confidence interval [CI], 1.73-9.61 for thiopurine alone and aOR, 4.01, 95 percent CI, 1.65-9.78 for combination therapy).

In addition, mesalamine or sulfasalazine monotherapy was also associated with an increased risk of severe COVID-19 (aOR, 3.52; p<0.001); while TNFi, again, was associated with protective effects and appeared to dampen the increment in severe disease risk when used in combination with mesalamine or sulfasalazine (aOR, 2.34; p=0.10).

Meanwhile, the use of anti-integrin or anti-interleukin 12/23 biologics was not associated with excess risk of severe COVID-19 compared with TNFi monotherapy.

What these mean for practice?

Elucidating how he would tailor IBD care based on the emerging evidence, Kappelman said “COVID-19 is perhaps another reason to favour anti-TNFs over 6-mercaptopurine or azathioprine.”

He also advised clinicians to “minimize corticosteroids … [but there is] no absolute contraindication.”

“I do not avoid 5-aminosalicylic acids in patients where this treatment has proven benefit, such as patients with ulcerative colitis and particularly those in remission; but it should be minimized or stopped in situations where it has questionable utility, [for instance,] in patients with Crohn’s disease or who are already on anti-TNF therapy,” Kappelman explained.  

“We have to adapt practice in accordance with emerging data,” he stated.

*SECURE-IBD: The international Surveillance Epidemiology of Coronavirus Under Research Exclusion
**ICU: Intensive care unit