I attended a briefing given by the American Gastroenterological Association (AGA) which was focused on COVID-19 and how the disease may affect people who live with inflammatory bowel disease (IBD). The briefing was given by three specialists: AGA Patient Education Advisor, Rajeev Jain, MD, AGAF, of Texas Digestive Disease Consultants; David T. Rubin, MD, AGAF, Joseph B. Kirsner Professor of Medicine, Chief, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Illinois; and Russell D. Cohen, MD, AGAF, Professor of Medicine, Director, Inflammatory Bowel Disease Center, University of Chicago Medicine, Illinois. Drs Jain, Rubin, and Cohen are all integral in the IBD community and generously lend their time and expertise to helping both healthcare professionals and patients better understand IBD. What follows are highlights from this presentation that illustrate what has been learned so far about the intersection of IBD and COVID-19.
Every person living with Crohn’s disease, ulcerative colitis, or indeterminate colitis is different. Check with your healthcare professionals about making any changes to your care plan. Currently, patients are being advised to keep taking their medications because staying in remission is the most important factor in avoiding complications from IBD as well as with COVID-19.
What Is SARS-CoV-2?
SARS-CoV-2 (Severe Acute Respiratory Syndrome CoronaVirus 2) is the name of the virus that’s causing the pandemic of 2020.1 It is also called the “novel coronavirus” because it is in the family of coronaviruses, of which there are several others that can affect humans. However, SARS-CoV-2 is “novel,” meaning “new,” in the sense that it has not infected humans before. SARS-CoV-2 is similar (to the tune of having 79.5% of the same genetic sequence) to SARS-CoV. SARS-CoV was the virus that caused an epidemic between 2002 and 2004, and which most people referred to as “SARS.”2
In many areas of the world, people are being asked, or required, to stay in their homes and avoid coming in contact with other people. For some areas, the need to physical distance in order to avoid spreading the virus in the community has been anywhere between several weeks to several months. One important piece of why SARS-CoV-2 is affecting some areas for such a long period of time is the incubation period. An incubation period is the time between when a person first comes in contact with the virus and time they get sick with symptoms. Incubation periods for different types of viruses can be anything from minutes to years. For SARS-CoV-2, the incubation period can be as long as 14 days. The average incubation period, however, is about 5 days.
Disease Course of COVID-19
COVID-19 (Corona VIrus Disease, which was discovered in 2019) is the disease that is caused by SARS-CoV-2. COVID-19 is considered a respiratory (lung) disease.3 The milder forms of the disease can cause few or even no symptoms. However, in some people, the illness progresses to a hyperinflammation phase, which can lead to complications such as acute respiratory distress syndrome (ARDS), systemic inflammatory response syndrome (SIRS), shock, and heart (cardiac) failure.
Shedding In Stool
One aspect of COVID-19 that is relevant to people who live with IBD or other digestive diseases is the potential for the virus to spread through stool. It’s currently known that parts of the virus may be found in stool but the live virus hasn’t yet been discovered in stool. What this means is that it’s probably not likely that infection can be spread through stool, however, it’s still important that people wash their hands properly after going to the bathroom.
Risk of Mortality in Patients with IBD and COVID-19
The SECURE-IBD Registry is an international database for people who live with IBD and are diagnosed with COVID-19. Those physicians who take care of people with IBD are being asked to enter information into this database when one of their patients develops COVID-19. There were a few pieces of information that have come from this database so far that the presenters wanted to highlight. Some of the risk factors that seem to be coming to light for being at-risk of dying due to COVID-19 include being male, having ulcerative colitis or indeterminate (unspecified) colitis, and being a current smoker.
In addition, other risk factors included having other diseases, called comorbidities (specifically 3 or more), and having moderate to severe IBD activity. As far as medications for IBD go, being treated with steroids was most often associated with being hospitalized.4
Editor’s Note: Readers may also note that the rate of death with JAK inhibitors (Xeljanz [tofacitinib]) seems high, but this is because 1 patient death among the small sample size (8 patients) will result in what looks to be a large percentage. More data is needed to make any firm conclusions about the JAK inhibitors.
Making Decisions About IBD Medications if COVID-19 Positive
The International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) has been holding meetings with a group of IBD specialists, in order to help gastroenterologists and patients understand how COVID-19 might affect people with IBD. This group looked at a variety of research and scenarios of IBD and COVID-19, including the SECURE-IBD Registry. They made some conclusions based on the information that we have right now. Some of these include how certain IBD drugs affect either the risk of COVID-19, or the course of the disease.
It’s thought that receiving prednisone at more than 20 mg a day increases the risk of infection and of developing COVID-19; that dosage should be lowered or stopped to avoid infection; and that patients should stop this drug upon a positive test for SARS-CoV-2 or COVID-19. (As always, any change in medications should be done under the supervision and direction of a healthcare team.)
Other medications that might be stopped upon a positive result for a COVID-19 test include Azathioprine/6-MP, Methotrexate, Anti-TNF drugs (Remicade [infliximab], Humira [adalimumab], Cimzia [certolizumab], Simponi [golimumab]), Stelara (ustekinumab), and Xeljanz (tofacitinib). It’s not recommended that 5-ASA drugs (mesalamine, sulfasalazine) be discontinued in the case of a positive test result.
Resources for People With IBD
Finally, the group had a number of resources available to recommend to patients. Some of the resources include medication assistance programs, ostomy supply information, and reliable sources for information about IBD and COVID-19.
I’d like to thank the AGA for inviting me to attend the briefing and Dr Jain, Dr Rubin, and Dr Cohen for presenting all the information in a way that was understandable and helpful for patient advocates. A special thank you to Dr Rubin who has been a leader in the IBD space since the beginning of the pandemic and has been providing a significant amount of digestible information via Twitter as well as being an author on several papers in an extremely short period of time.
Jain R, Rubin DT, Cohen RD on behalf of the American Gastroenterological Association. IBD Treatment and COVID-19. Presented on April 17, 2020.
- Lesney M. “SARS-CoV-2: What’s in a Name?” Medscape.com. 25 Feb 2020.
- di Mauro Gabriella, Cristina S, Concetta R, Francesco R, Annalisa C. SARS-Cov-2 infection: Response of human immune system and possible implications for the rapid test and treatment [published online ahead of print, 2020 Apr 16]. Int Immunopharmacol. 2020;84:106519. doi:10.1016/j.intimp.2020.106519
- American Lung Association. Coronavirus Disease (COVID-19). 2020.
- Brenner EJ, Ungaro RC, Colombel JF, Kappelman MD. SECURE-IBD Database Public Data Update. covidibd.org. Accessed on 04/16/2020.
- Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). frequently asked questions. 9 May 2020.
- Ferguson NM, Laydon D, Nedjati-Gilani G, et al on behalf of the Imperial College COVID-19 Response Team. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. 16 March 2020.
- Lauer SA, Grantz KH, Bi Q, et al. The incubation period of coronavirus disease 2019 (COVID-19) From publicly reported confirmed cases: Estimation and application. Ann Intern Med. 2020;172:577-582. doi:10.7326/M20-0504
- Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020;382:1199‐1207. doi:10.1056/NEJMoa2001316
- Linton NM, Kobayashi T, Yang Y, et al. Epidemiological characteristics of novel coronavirus infection: A statistical analysis of publicly available case data. medRxiv [Internet] 2020 [cited 2020 Feb 18]. doi:2020.01.26.20018754
- National Institutes of Health. Acute respiratory distress syndrome. Department of Health and Human Services. 17 Sept 2019.
- Wölfel, R., Corman, V.M., Guggemos, W. et al. Virological assessment of hospitalized patients with COVID-2019. Nature. [Published online April 1, 2020]. doi:10.1038/s41586-020-2196-x