Best Practices in the Management of IBD During COVID-19 - Episode 2
Miguel Regueiro, MD: You talk about this progressive nature of both ulcerative colitis and Crohn disease. There is a clear impact on the quality of life. Patients live with chronic diseases, and IBD [inflammatory bowel disease] has been looked at as having, unfortunately, 1 of the poorest qualities of life. Crohn disease complications include strictures, fissures, and a need for surgery. For patients with ulcerative colitis, as you said, sometimes colectomy is there for refractory disease, but there is a lack of compliance in the bowel, rigidity of the bowel, and scarring of the bowel, which we haven’t thought about for ulcerative colitis. Even now, it is cancer, obviously, although the colon cancer rates seem to be going down fortunately, and that may be because of better treatment.
Jean-Fred, we’re living in the era of COVID-19 [coronavirus disease 2019], and our patients and physicians are worried about these chronic diseases. Is the incidence of IBD in COVID-19 higher? Does walking around with IBD mean that our patients are more likely to get COVID-19?
Jean-Frederic Colombel, MD: It’s a good question, Miguel, and the short answer is this: I don’t know. I don’t know because there are no good population-based studies. There are some data from Italy that were published in Gastroenterology, for instance, showing no increased incidence. Let’s talk about the risk of getting COVID-19 when you have IBD. There is basically no increased risk compared with the general population.
Just yesterday, there was a meta-analysis published in a hematology journal looking across all IMiDs [immunomodulatory imide drugs], and what they found was an approximately 2-fold increase risk of getting COVID-19 when you have IMiDs, but this was actually attributed to the use of steroids. This means that, to make a long story short, there are no data showing that IBD is a risk factorper se, but for medication and certainly steroids, we will talk about that. The second question is this: If you get COVID-19 and have IBD, what’s your outcome? There is our question.
Miguel Regueiro, MD: The comforting thing so far is that, for patients who have inflammatory bowel disease, such as Crohn disease or ulcerative colitis, we’re not seeing higher rates of COVID-19. As you alluded to, in all immune-mediated diseases, prednisone steroids probably are the bad actor.
That’s a nice segue as I think about the RAND analysis. Doug, I’ll ask you this. There was a RAND analysis put together that was published in Gastroenterology. The RAND analysis, for those out there, is a group of experts—and we can define experts however we want—who get together and come up with an analysis based less on data but more on opinion: knowledge of past diseases and referral to other diseases. The RAND analysis looked at medicines. Doug, what’s your sense of the RAND analysis that was run on the medicines we have in IBD? Are we seeing more problems with these medicines? What’s your overall sense from that?
Douglas C. Wolf, MD: The RAND analysis or panel is a group of experts who made the best judgments they could on what role these different medications should have and how they should be changed in the era of COVID-19. The general message is that, except for an even more judicious use of corticosteroids than before, everything should be continued as is. With that, there is 1 comment that if someone does contract COVID-19, they should be held for the period of active symptoms or active-test positivity, and that’s typically 10 to 14 days. There can be exceptions.
A medication might be held in that period, but otherwise, there is no good evidence that other medications need to be changed. In fact, I’ll add that there is a suggestion. We’ll talk about the SECURE-IBD [Surveillance Epidemiology of Coronavirus Under Research Exclusion] registry later on perhaps, but there may be a suggestion that some types of medications are even protective.
Miguel Regueiro, MD: That’s a great segue. You mentioned the SECURE-IBD registry, and I’m going to ask Jean-Fred about it. I know you’ve been involved and thinking a lot about it, and I know Dr Ryan Ungaro is with you there at [the Icahn School of Medicine at] Mount Sinai. The simple question is this: What’s the SECURE-IBD registry, and what are the practical take-home points from the SECURE-IBD registry?
Jean-Frederic Colombel, MD: Miguel, the SECURE-IBD registry is a web proctor registry in which gastroenterologists from all over the world voluntarily report their cases, completely anonymously, and then enter their data once they have 1 patient who has IBD and COVID-19. The main goal of SECURE-IBD is to look at the impact of risk factors, including medications, on the outcomes of COVID-19. The bad outcomes include hospitalization, ICU [intensive care unit], and death. We now have almost 3000 patients from all over the world. We found some classical findings. Age is a strong risk factor. Comorbidities are also a strong risk factor for bad outcomes.
Most interesting are data about medications. Doug is absolutely right: Steroids are bad. A steroid is a driver of bad outcomes. The most recent data is interesting, and there are data that should be published soon as well showing that azathioprine and other thiopurines are bad drivers as well, as is combination therapy, which means that we should do everything possible in our IBD patients to wean them off steroids. Personally, if they are on combination therapy, I would try to stop combination therapy because azathioprine is a bad habit, which is not a big surprise given the history of this drug.
Apart from that, all biologics look good so far, and as Doug was saying, there is even some evidence that some biologics, especially anti–TNF [tumor necrosis factor] and ustekinumab, may have a protective role. I want to be very cautious, but there are actually some ongoing trials with anti-TNF in patients with COVID-19, not talking about IBD patients. These are very important data, and I completely agree with Doug. It is quite reassuring data. As far as medication is concerned, we can continue. We shouldn’t hold most of our therapies except for steroids and thiopurines.
Transcript Edited for Clarity