SECURE-IBD Sheds Light on COVID-19 Risks for Patients With IBD

Patients with IBD who are being treated with therapeutics other than corticosteroids are at no higher risk of hospitalization, ICU care, ventilation, or death than the population as a whole, according to data collected through the SECURE-IBD registry—a topic Bincy Abrahams, MD, and Tauseef Ali, MD, discussed at the Advances in Inflammatory Bowel Disease (AIBD) virtual regional meeting held on September 26.

Dr Abraham is the director of the Fondren Inflammatory Bowel Disease Program at Houston Methodist Hospital in Houston, Texas, and cochair of AIBD 2020. Dr Ali is chief of the Gastroenterology Section at SSM Health Saint Anthony Hospital in Oklahoma City, Oklahoma, and clinical assistant professor of medicine at the University of Oklahoma.

The SECURE-IBD registry was developed via an international collaboration of organizations and medical specialists “to rapidly define the impact of COVID-19 on patients with IBD, including the impact of factors such as age, comorbidities, and IBD treatments on COVID outcomes,” and “to provide regular updates (weekly) to the IBD community regarding number of reported cases and outcomes, including data broken down by geographic region and IBD treatment.”

As of September 21, 2364 cases, 583 hospitalizations, and 67 deaths worldwide had been reported to the registry. In the United States, SECURE-IBD has recorded 936 cases, 583 hospitalizations and 7 deaths.

Dr Abraham reported that the highest percentages of ICU admission (15%) and ventilation (12%) occurred in patients from 60 to 69 years of age, while the death rate was highest among patients over age 80 years (27%). Patients with moderate to severe IBD and 3 or more comorbidities have shown the highest rates of ICU admission, ventilation, and death, at 9% and 38%, respectively.

She also reported on the hospitalization and death rates among patients with IBD based on the therapy being used to treat their IBD. Those being treated with steroids had the highest death rate by far, at 19%, Dr Abraham stated, while patients on anti-tumor necrosis factor (TNF) monotherapy had the lowest, at 2%.

She explained that many patients being treated with immunosuppressant medications voiced concerns about continuing their therapy during the pandemic, fearful that their suppressed immune systems would place them at increased risk of contracting the virus. Dr Abraham noted that to date, the results of analysis of the SECURE-IBD data indicate it is safe for patients to continue therapy unless they are being treated with corticosteroids. “In fact, our goal is to keep our patients on their therapy to keep their disease in remission,” she explained. “This prevents the need for using steroids to control flares of IBD.”

Dr Ali reviewed the use of personal protective equipment (PPE) in treating patients with IBD and the American Gastroenterological Association’s (AGA) recommendations. He noted that these guidelines call for the use of N95, N99, or powered air purifying respirator (PAPR) masks for upper and lower GI procedures—regardless of the patient’s COVID-19 status—instead of a surgical mask. The recommendations allow for reuse of N95 masks “in extreme resource-constrained settings.” He noted that in his own facility, the staff had to reuse N95 masks for 3 days early in the pandemic due to supply shortages.

He also explained that the AGA recommendations call for a “negative pressure room for any GI procedure in known/presumptive COVID-19” cases. “This is of course problematic for ambulatory surgical centers, where negative pressure rooms aren’t usually available, but it remains a recommendation,” Dr Ali said.

Drs Abraham and Ali reviewed some hypothetical cases involving patients with IBD who have been exposed to COVID-19, who test positive for the virus, and who actually become symptomatic.

For patients who have been exposed, Dr Abraham said, “there are 2 steps: define the patient’s exposure and determine if the patient has any symptoms. Close contact is defined as a total exposure time of more than 15 minutes at a distance of less than 6 feet; any direct physical contact; sharing food, beverages, or utensils; and exposure to respiratory droplets such as from a cough or sneeze, with a person who has tested positive for COVID-19.” If the patient with IBD has no symptoms, that person should self-isolate for 14 days. If the patient has any symptoms of COVID-19, then the patient should get tested.

The International Organization for the Study of Inflammatory Bowel Disease (IOIBD) recommends continuing medications other than prednisolone in patients with IBD who have been exposed but have not tested positive for COVID-19. For those who do test positive but remain asymptomatic, IOIBD recommends continuing 5-ASAs and anti-TNF monotherapy but stopping the use of 6-mercaptopurine and methotrexate. For patients who have COVID-19 symptoms, IOIBD recommends continuation only with 5-ASAs.

“With the immunotherapies, we have to judge based on the type of therapy, the condition of the patient, severity of IBD and COVID-19, and other factors,” Dr Abraham said. “And in fact, there has been a lot of discussion about how COVID-19 initiates a ‘cytokine storm,’ so the anticytokine medications for IBD could possibly calm down this storm and have a positive effect.” She stressed that “we do need to try to get our patients off steroids and onto a biologic. Get them to the lowest possible dose and taper them off, if at all possible.”

On the question of continuing infusion treatment for patients with IBD who have tested positive for COVID-19, Dr Abraham noted that some infusion centers may not accept COVID-positive patients. “It’s an issue of protecting other patients at the center from possible exposure,” she explained. “Try to delay infusion until the patient tests negative, but not so long that they end up having a flare.” In her own practice, Dr Abraham found that the majority of her patients with IBD who tested positive remained asymptomatic or had very mild symptoms. In general, she holds the use of immunosuppressive medications, including JAK inhibitors, until her patient has a negative COVID test following exposure. “The half-life is pretty long with most biologics, so there may still be drug on board, even if you hold it a bit,” giving patients some continued protection against flares.”

Dr Ali noted that in his practice, many of his patients with IBD evidence "high-risk behavior” in terms of protecting themselves against COVID-19. “The reliability of their self-isolating and wearing masks is poor.” As a result, knowing when to resume treating these patients with immunosuppressive drugs “is very challenging. In addition, many patients have lost jobs and lost their insurance or changed insurance,” which further complicates treatment decisions.

“We can delay infusion and immunosuppression; after 10 to 14 days with no symptoms, we can start medication again, but if the patient is high-risk, we recommend that they get tested again,” he said.

--Rebecca Mashaw

Abraham B, Ali T. Regional update on COVID-19 and IBD. Presented at: Advances in Inflammatory Bowel Disease 2020 regional, Houston; September 26, 2020; virtual.