COVID-19 appears milder in patients with IBD

Last Updated: 2020-04-09

By Will Boggs MD

NEW YORK (Reuters Health) - The disease course of COVID-19 appears to be milder in patients with inflammatory bowel disease (IBD), according to two new reports.

IBD patients often receive immunosuppressive treatments, which raises concerns about whether they are more susceptible to COVID-19. On the other hand, immunomodulatory therapies might also suppress the hyperinflammatory cytokine response associated with the most severe presentations of COVID-19.

Dr. Lorenzo Norsa from Papa Giovanni XXIII Hospital, in Bergamo, Italy, and colleagues describe the experience of their IBD center during the COVID-19 pandemic in an area with one of the highest rates of SARS-CoV-2 infection per 100,000 inhabitants worldwide.

The 522 patients with IBD in their center were advised not to modify their treatment regimens. There were no reported cases of COVID-19 in this group, and no patients were admitted to hospital with proven SARS-CoV-2 infection.

Based on their calculations using data from the Wuhan region, however, there should have been 21 cases among their IBD patients.

In contrast, during the same period, 479 patients without a history of IBD were admitted to their hospital because of severe COVID-19 after presenting to the emergency department with respiratory failure, the authors report in Gastroenterology.

In the previous SARS and MERS coronavirus outbreaks, they note, immunosuppression was not found to be a risk factor, and no patient with IBD as the only risk factor was reported to develop severe SARS or MERS-related disease.

"These findings warrant further investigation, to confirm our preliminary findings and allow implementing guidelines on the management of these patients during the SARS-CoV-2 global pandemic," Dr. Norsa and colleagues conclude.

In another report, published in the Journal of Pediatric Gastroenterology and Nutrition, Dr. Dan Turner of Shaare Zedek Medical Center at The Hebrew University of Jerusalem, in Israel, and colleagues from centers around the world provide provisional guidance for managing pediatric IBD in the face of COVID-19.

They identified eight children with pediatric IBD globally who developed COVID-19, all with mild infections not requiring hospitalization, despite treatment with immunomodulators and/or biologics.

None of these cases were from China or South Korea, but 17 (22%) of 79 children there had exacerbations of their IBD after biologic treatment was delayed.

Elsewhere, face-to-face appointments were often replaced by remote consultations but almost all maintained current IBD treatment.

Based on the available evidence and on consensus rates ranging from 92% to 100%, the group issued 10 guidance points for clinicians caring for pediatric IBD patients in pandemic areas.

They conclude that IBD per se does not seem to be a risk factor for acquiring SARS-CoV-2 or for a more severe infection, so they recommend using the same measures as the local population for decreasing the risk of contracting SARS-CoV-2 in these children.

Active IBD should be treated according to standard guidance, as before the pandemic, since the risk of IBD complications in active IBD outweigh the risk of COVID-19 complications, especially in children.

Along the same lines, there appears to be no clear indication to stop IBD treatment during COVID-19 infection, but the group recommends suspending immunosuppressive treatment during an acute febrile illness until fever subsides and the child returns to normal health, irrespective of the SARS-CoV-2 testing status.

Children should continue follow-up visits, preferably by remote telemedicine consultations, and elective surgeries and nonurgent endoscopies should be postponed during the pandemic, the authors say.

Dr. Giovanni Monteleone of the University of Rome Tor Vergata, who recently reviewed evidence suggesting that IBD patients are not at increased risk for COVID-19, told Reuters Health by email, "Cytokine blockers may actually have a beneficial effect. Indeed, early research suggests that interleukin-6 receptor blocker may be helpful for treating COVID-19 pneumonia."

"IBD patients should continue to take their drugs," said Dr. Monteleone, who was not connected to the new reports, "but it is important they must stop smoking, as this seems to be a factor increasing the risk of infection."

Dr. Silvio Danese of Humanitas University, in Milan, Italy, who recently reviewed the management of IBD during COVID-19, told Reuters Health by email that it remains unclear why IBD patients seem to be protected from COVID-19.

"We don't know if it is (the disease itself) or drugs protecting the patient, or if patients might be better with social isolation, as they know about their immunosuppressed status," said Dr. Danese, who also was not involved in the new studies.

While he admits that "we are still learning," he endorses following the current recommendations of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), which can be found at https://bit.ly/3e9b49m.

Dr. Norsa and Dr. Turner did not respond to a request for comments.

SOURCE: https://bit.ly/2RhbosT Gastroenterology, online April 2, 2020.

https://bit.ly/2VcLPdB Journal of Pediatric Gastroenterology and Nutrition, online March 31, 2020.