Best Practices in the Management of IBD During COVID-19 - Episode 3

Anticytokine Therapy for IBD and COVID-19

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Miguel Regueiro, MD: Doug Wolf and Jean-Fred, that’s interesting both from the RAND analysis and the SECURE-IBD [Surveillance Epidemiology of Coronavirus Under Research Exclusion—Inflammatory Bowel Disease] registry. Everybody agrees that corticosteroids are the bad actors, especially with the higher doses. Jean-Fred, you’ve been a big investigator of how viruses with thiopurines, and we’ve talked about this with BBB [blood-brain barrier] and now maybe with COVID-19 [coronavirus disease 2019]. I think we need to pause and wait for the complete data, but I also wonder if thiopurines could potentially have a negative effect.

If I have a very sick patient with IBD [inflammatory bowel disease], and they’re on thiopurines and I think they need to be on that for combination, I’m not stopping that. But I do think we need to look out for that. Both of you, interestingly, mentioned that there may be a protective effect or benefit more likely in COVID-19. For our audience out there, to mention what both Doug and Jean-Fred are alluding to, there may be benefit with the anticytokine medicines, maybe even the small molecules, JAK inhibition. If you have the cytokine storm, if you are very sick from COVID-19, why are people in the ICU [intensive care unit]? It’s probably the systemic inflammatory response of the immune system. We may be contradicting ourselves, but that’s why the London or the UK [United Kingdom] study on how low-dose dexamethasone in somebody in the ICU who is very sick may help. To both Doug and Jean-Fred’s point, this may be ustekinumab, adalimumab, and maybe even the JAK inhibitor tofacitinib, but this is not for any of us to go out and start using these medicines to treat COVID-19. This is in research, and we need to learn more.

Jean-Frederic Colombel, MD: I fully agree, Miguel. We are learning every day. We are getting more data, more results. Knowledge is changing every day. You are absolutely right. It may be confusing for some people because they know the story about the dexamethasone in several patients, and we are now coming with a story that steroids are bad. These are 2 different phases of the disease, so steroids are bad at the initial phase, and then they can be good at the phase of COVID-19 expansion when you have this cytokine storm.

I fully agree with you about your interpretation. This protective effect in the market of anti–TNF [tumor necrosis factor] may be used for their anticytokine impact at a systemic level. Interestingly, in the SECURE-IBD, we didn’t find any evidence of protective for role vedolizumab, for instance. It is a gut-selective agent, which makes perfect sense.

Miguel Regueiro, MD: It’s interesting. COVID-19 is 1 of those things where what we knew a month ago feels like 2 years ago, and what was published at the beginning, in March, is already outdated. It’s an evolving topic.

Transcript Edited for Clarity