As we enter the last days of 2020, we gather (virtually!) at AIBD to review and debate what we learned over the year. No topic induced as much fear, anxiety, and reactionary care as the arrival of coronavirus. This topic was prominently featured in the Friday session where they addressed risk and outcomes for people living with IBD, how to manage IBD medications during the pandemic, and the safety and efficacy of the vaccines.
The first discussion was if people living with IBD are more likely to get COVID-19 and have worse outcomes. Dr Abreu described how SARS-CoV2 uses the ACE2 receptor to enter cells, including those in the GI tract. Patients with IBD do not have increased expression, so are not more likely to get COVID-19. This data is supported by our real world registries. The ICARUS-IBD is an international effort to prospectively measure serum antibodies to COVID-19 longitudinally, and determine incident rates along with factors associated with spread. The SECURE-IBD is a de-identified registry to track outcomes. There is little to no increased risk of severe COVID-19 (hospitalization, ventilator, death) due to illness, though there is a signal that 5 ASA, thiopurine monotherapy, and combination therapy with thiopurines have more severe disease.
All panelists supported the continuation of maintenance IBD medications. The reason is that corticosteroids showed the strongest association with adverse outcomes, including an 8% risk of death. Avoiding flares and hospitalization were considered a top priority. Interestingly, in SECURE-IBD, the OR for death while on Anti-TNF was 0.4. There is ongoing research into Anti-TNF and JAK-i as potential therapies during severe COVID-19 to prevent or treat ARDS by blocking the cytokine storm thought to be responsible for the destruction of pulmonary tissue. Anti-IL 12/23 and anti-integrin agents were not found to increase the risk of severe COVID-19.
Other factors that have been found to be associated with worse outcomes while infected with COVID-19 include older age and increased comorbidities. While ICARUS-IBD used a cut off of 65 years old, the mortality rate in SECURE-IBD increased with age and peaked in octogenarians at 27%. While they did not describe the individual comorbidities that conferred risk, when patients with two or more comorbidities got COVID-19, the risk of death increased by 21%.
Another area of concern for gastroenterologists is that SARS-CoV2 can survive in the stool. The issue is potential fecal oral spread, particularly during endoscopy. Dr. Abreu mentioned that currently we have no data that infections have been spread this way. Continued use of PPE, including masks, are paramount to safe endoscopy.
As of yet we do not have data on safety and efficacy of the vaccines in IBD patients in general, or while on medications. The vaccine is an mRNA that is given over two shots. When polled, each member of the panel would recommend the vaccine as being safe for their patients. We know from other vaccines, such as influenza and hepatitis B, that patients with IBD have decreased seroconversion. Part of this may be due to the underlying disease and part due to the medications they are taking. To date we do not have any data on how patients with IBD on medications respond to the vaccines. The panel again unanimously voted that they would vaccinate their patients.
The coronavirus has changed our way of life, but the efforts of so many across the globe to research the disease, prevent its spread, come up with better treatments and find vaccines will lead us to a safer tomorrow. New information is being integrated into our recommendations at a dizzying speed. Together we can provide our patients with the best care possible.
Illustration by April Brust