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Immune suppression is a common strategy to treat inflammatory bowel disease (IBD) and is understood to increase the risk for SARS-CoV-2 infection. To track outcomes of COVID-19 in patients with IBD, an online international registry was established in late March. Outcomes in 525 patients from 33 countries have been reported; 31% of patients have been hospitalized, and the case fatality rate is 3%.
Using these data, researchers assessed risk factors for severe COVID-19 (intensive care unit admission, ventilator use, or death), which occurred in 7% of patients. In multivariable analyses, steroid use was associated with a sevenfold increased risk for severe disease (odds ratio, 6.9; 95% CI, 2.3–20.5), mesalamine use with a threefold increased risk (OR, 3.1; 95% CI, 1.3–7.7), and anti–tumor necrosis factor agent (anti-TNF) use with no excess risk for severe disease.
Brenner EJ et al. Corticosteroids, but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients with inflammatory bowel diseases: Results from an international registry. Gastroenterology 2020 May 18; [e-pub]. (https://doi.org/10.1053/j.gastro.2020.05.032)
Comment
Previous work demonstrates that steroids are associated with worse clinical outcomes compared with other treatments in IBD, and therefore the increased risk here is not surprising. However, the observation that mesalamine — an agent that works topically without influence on the immune system — was associated with a higher risk for severe disease seems somewhat counterintuitive. One explanation might be that after diagnosis with COVID-19, patients are having their immune suppressants discontinued, resulting in active inflammation which leaves them vulnerable to worse outcomes. Another intriguing finding is the lack of association with anti-TNF therapy. The authors hypothesize that anti-TNF therapy may be protective by inhibiting the cytokine storm that can occur in very ill patients. The apparent takeaway for management of an IBD patient with COVID-19 is to control inflammation and avoid steroid use.