Patients with inflammatory bowel diseases (IBD) typically present a robust antibody response after the third and fourth dose of mRNA vaccine, Ryan Ungaro, MD, MS, explained in a panel discussion at the Advances in Inflammatory Bowel Disease annual meeting in Orlando, Florida, on December 6.

The expert panel—Neilanjan Nandi, MD, FACP; Gilaad Kaplan, MD, MPH; Frank Farraye, MD, MSc; and Jessica R Allegretti, MD, MPH—presented case studies to encourage gastroenterologists to address individual patient characteristics, the role of PCR testing, varicella zoster virus (VZV) vaccination, and the updated recommendations for COVID-19 vaccination and their impact on IBD medications, before prescribing medication to manage IBD.

Dr Ungaro is an associate professor of medicine at Icahn School of Medicine at Mount Sinai at New York, New York, and the cofounder of the Surveillance Epidemiology of Coronavirus under Research Exclusion (SECURE-IBD), on online collaboration to guide IBD management in the COVID-19 era.

Dr Nandi is an associate professor of clinical medicine at the University of Pennsylvania and Penn Presbyterian Garnet Valley in Pennsylvania. His areas of expertise include abdominal distention, acute pancreatitis, anal fissure, and autoimmune enteropathy.

Dr Kaplan is a professor and gastroenterologist in the Cumming School of Medicine at the University of Calgary in Calgary, Alberta. His research programs focus on the global burden of digestive diseases, environmental determinants of IBD, and overall improvement and care of patients living with digestive diseases.

Dr Farraye is a senior associate consultant in gastroenterology and hepatology and a professor of medicine at the Mayo Clinic in Jacksonville, Florida. He specializes in vaccine optimization, eating disorders, artificial intelligence, diagnosis of Clostridioides difficile infection, and stigma and disclosure among patients with IBD.

Dr Allegretti, a recipient of the Sherman Emerging Leader Prize in 2020, is medical director of the Crohn’s and Colitis Center at the Brigham and Women’s Hospital in Boston, Massachusetts. Her research focuses on the intestinal microbiome and their consequences and understanding the role of dysbiosis in microbial associated diseases.

The panel spoke about the role of cytomegalovirus (CMV) infection in worsening the severity of inflammation in ulcerative colitis (UC). The challenges for gastroenterologists include landing upon the correct optimal diagnostic tests for CMV infection and determining the optimal time to initiate antiviral treatment. “Patients with CMV infection and acute severe colitis are more resistant to treatment with corticosteroids than noninfected patients,” Dr Ungaro said.

The discussion cited a case study of an adult female with pancolitis on adalimumab 40mg/ 2 weeks flaring on prednisone 40mg daily. The panelists said that while studies have showed no effect of antiviral treatment on colectomy rates among CMV-infected patients with UC, significant differences in colectomy rates of patients with high-grade infection who received antiviral therapy were seen compared to those who did not receive treatment.

The second scenario focused on managing VZV with non-JAK inhibitors and questions about altering treatments and vaccinating patients with IBD against VZV. The risk of VZV infection is increased significantly with all immunosuppressants used in the treatment of IBD, but corticosteroids and combination of certain immunosuppressants appear to pose a higher risk.

These various atypical manifestations of primary and secondary VZV infections among patients with digestive disorders should be screened before initiating any antiviral treatments. Consultation with an infectious disease expert would help too, the panel agreed.

Finally, the panel discussed COVID-19 infection combined with IBD activity and antiviral treatments. Should clinicians delay the infliximab infusion in that case? Prescribe any antiviral therapies to these patients? What is the impact of COVID-19 vaccine recommendations on concomitant medications? The expert panel encouraged physicians to screen patients for these data and initiate discussion with the patient before finalizing a treatment plan through shared decision making.

Among patients with IBD, the risk factors for hospitalization for severe COVID-19 included age (more than 60 years old), non-IBD comorbidities (2 or more in addition to IBD), moderate to severe disease activity, use of corticosteroids, and combination therapy of anti-TNF and thiopurine.

Dr Ungaro stressed the benefits of the booster shots for COVID-19 owing to the robust antibody response seen among patients with IBD. Additionally, any adverse events following vaccination were similar to those from resulting from COVID-19 infection; these vaccines have been proven safe among individuals with IBD.

Viral infections in immunosuppressed patients may manifest in different ways in different patients, which may present a challenge to gastroenterologists in treating each. “Owing to their atypical signs and symptoms, clinicians may find it difficult to suspect, recognize, and diagnose complications,” Dr Ungaro said. “Appropriate treatment of common viral infections allows us to minimize their impact on disease outcomes and patients’ lives.”

—Priyam Vora

Reference:

Ungaro R, Nandi N, Kaplan G, Farraye F, Allegretti J. Viral infections and IBD. Presented at: Advances in Inflammatory Bowel Disease Annual Meeting; December 6, 2022. Orlando, Florida.