I enjoyed attending the session “A Lens of COVID-19 and IBD”, specifically those chaired by Dr. Maria Abreu, Dr. Michael Kappelman and Dr. Brennan Spiegel. We reviewed some basics of COVID-19 pathophysiology, updates from data gathered from the Secure-IBD Registry, European updates and the role of digital health in IBD in the era of COVID-19.
If you want a little background or review of the virus before we dive in, COVID-19 is a single-stranded RNA virus that is spread primarily by respiratory droplets (coughing, sneezing, etc.). We know that disease severity of COVID-19 varies greatly, from some people being completely asymptomatic to those who are so ill they need care in the ICU. They can include, but are not limited to, fever, cough, shortness of breath, nausea, vomiting and diarrhea. Studies have shown that patients can have prominent GI symptoms, especially in patients who are hospitalized.
Good news that we have found out through studies are:
IBD patients are not more susceptible to COVID-19 than others - there is not evidence supporting this so far.
COVID-19 is present in stool and can infect cells grown in a culture in a lab, but there are no known cases from contaminated stool.
Biologic medications, such as anti-TNFs (think Humira), JAK-inhibitors (think Xeljanz) or anti-interleukins (think Stelara) seem to be potentially beneficial in COVID-19 infection. Some of these therapies are being looked at further as potential COVID-19 treatments.
Some information that we know could potentially make COVID-19 worse in IBD patients:
COVID-19 causes dysbiosis in the microbiome, and we know that there is a relationship between dysbiosis and disease severity.
A study from the Veterans Affairs (VA) system showed that COVID-19 severity was more dependent on comorbid conditions than being on thiopurine medication. This means that the more chronic conditions you have, the more likely a course of COVID-19 is to be severe.
Broad immunosuppression appears to lead to worse outcomes. So, taking a medication like prednisone that broadly suppresses all arms of your immune system is not ideal. However, if you are in a situation where your body needs prednisone, then your GI provider may weigh the risks/benefits of these medications.
There is some data that suggests that mesalamine and sulfasalazine medications could lead to slightly worse COVID-19 infections.
The next segment of this discussion focused on updates from the Secure-IBD registry, a voluntary reporting system for COVID-19 occurring in IBD patients that started in mid-March. This system has been utilized by IBD providers in 62 countries and 47 US states as of late November. The mean age reported in 40 years old, and 57% of patients have Crohn’s disease. From the data we have, it is difficult to say if there is true increased mortality risk in IBD patients since we need more data and we are still learning about this novel virus. Here are some highlights from the other statistically significant data from the registry:
Pediatric IBD patients appear to do quite well, which is in line with findings from the rest of the pediatric population.
There is a strong trend with increasing age by decade and need for hospitalization and even death, but this also matches data on non-IBD patients.
IBD patients with COVID-19 do have more GI symptoms, with abdominal pain and diarrhea being hallmark.
Anti-TNF biologics seem to have a protective effect against COVID-19, and this matches data coming from the rheumatoid arthritis (RA) community as well.
Combination therapy with immunomodulatory medications seems to lead to more requirements for ICU admission or severity, but this will continue to be closely monitored as more data is gathered.
Lastly, we looked at the role of digital health in IBD; Dr. Brennan Spiegel has been doing research with virtual reality (VR) headsets with his IBD patients, specifically as a way to target intractable abdominal pain and other forms of chronic pain that IBD patients deal with in the hospital setting. VR has long been used in studies about pain and perception, and was found to reduce anxiety and self-administered Propofol (that nice sleepy drug we all get!) during routine colonoscopies back in the 1990s. For many of us watching, we are so excited to see a non-pharmacological treatment utilized for IBD patients. We hope this can become widely available and affordable for all patients and that we can find ways to use it in outpatient settings. If you are interested, Dr. Spiegel suggested visiting virtualmedicine.org and clicking under the “Clinical Tools” link to learn more and explore products. Do you think using VR as a way to treat pain could be a long-term addition to a comprehensive team approach to treatment?
It was great to hear from multiple experts about COVID-19 and IBD. I think that, all in all, the data so far shows that we are not as high risk compared to the general population as we originally thought. I find it hopeful that some of the biologic medications many of us take are considered to be protective. Yet, the most important things we can do now is to continue to be careful, social distance, wash hands, and wear your masks religiously. I hope to see digital tools continue to be utilized not only with telemedicine appointments, but with ways to innovate and find treatment options such as VR that complement medical treatments for IBD.