Inflammatory Bowel Disease in the Pandemic

A guide for IBD patients to better understand their risks during COVID-19.
All the headlines, information and misinformation regarding COVID-19 and inflammatory bowel disease (IBD) may cause understandable confusion about what enhanced risks you really face as an IBD patient during the pandemic. How do you reduce your risk? What medications put you at greater risk contracting COVID-19? What happens if you contract the disease?

You can use this guide to better evaluate risks and the mitigation strategies to stay safe.
If you have IBD, you already know your immune system in your intestines is in overdrive, says David Rubin, M.D., chief of the section of gastroenterology, hepatology and nutrition, and co-director of the Digestive Diseases Center at the University of Chicago. In 2021, Rubin will also be the chair of the National Scientific Advisory Committee of the Crohn's & Colitis Foundation. “[That’s] either because something is continuing to stimulate it or because [your] body has lost the ability to regulate it and shut it down or turn it off.” It’s this overdrive response that causes inflammation of the gastrointestinal tract and, if you suffer from Crohn’s disease or ulcerative colitis, you likely face a multifaceted regime of medications and therapies to help manage your symptoms.

There are six different medication categories for IBD patients, depending on your diagnosis and symptoms: antibiotics, aminosalicylates, immunomodulators, corticosteroids, biologic therapies and Janus kinase (JAK) inhibitors, and Rubin says the goal of most of these is to turn down your body’s overactive response so it can reset itself.

Medical Treatment for Inflammatory Bowel Disease and How is the Immune System Affected?

Treatment
How is the Immune System Affected?
Definition
Not Suppressed
Suppressed
Medication
Modified
Treatment: Antibiotics
Helps with inflammation of the intestines and treats infections that arise as a complication of IBD.
The Immune System is...Not Suppressed
Treatment: Aminosalicylates
Compounds that contain 5-aminosalicylic acid (5-ASA) and reduce inflammation in the intestine.
The Immune System is...Not Suppressed
Treatment: Immunomodulators
Modifies immune system activity and decreases inflammatory response.
The Immune System Could be BothNot Suppressed
And/Or Modified
Treatment: Corticosteroids
Lowers immune system activity and limits inflammation in the digestive tract.
The Immune System is...Not Suppressed
Treatment: Biologic/Biosimilar Therapies
Made from natural proteins to target the immune system.
The Immune System Could be Both...Not Suppressed
ANd/or Modified
Janus Kinase Inhibitors
Small molecule compounds absorbed into the bloodstream that block pathways of inflammation to the intestines.
The Immune System is...Not Suppressed
Sources: Crohn's & Colitis Foundation
While all IBD patients need to be more vigilant during the pandemic, those taking corticosteroids, especially in higher doses, face higher risks of hospitalization and complications if they are infected with the coronavirus associated with COVID-19.

Steroids and Inflammatory Bowel Disease

The introduction of steroids to treat IBD in the 1950s changed the game for managing both Crohn’s disease and ulcerative colitis. “We’ve learned a lot more about steroids since then, however,” Rubin says.  

While steroids are effective at reducing inflammation and getting an IBD patient into remission, they don’t actually heal the bowel. Rubin is quick to point out that steroids are not maintenance medications, and if they’re part of your treatment, you should use them as a bridge to improve symptoms so other therapies can help repair the bowel. 

Drawbacks of steroids may include: psychosocial impacts such as sleep disturbance or anxiety, infection, bone loss, neurological changes and even physical appearance changes (such as weight gain, acne and swelling), and these adverse effects could be worse with higher doses and longer exposure, Rubin says. “In general, a patient who needs steroids more than once in a year needs to be on a more effective maintenance strategy for disease control.” 

He continues: “Keeping patients with IBD in remission is key to keeping them healthy during the pandemic.” 

So is it safe for you to be on steroids while COVID-19 continues to spread? “We’ve learned that using them long-term isn’t acceptable even before and certainly during a pandemic,” Rubin says. “Get on medicines that can keep you off steroids and that will keep you healthy long-term. Our modern therapies are specifically suited to be steroid-sparing.”   

IBD Patients and COVID-19: What to Know

The key goal for IBD patients, whether during the pandemic or in more “normal” times, is clear: to partner with the patient to achieve a deep remission (mucosal healing) and while working toward that goal we strive to keep inflammation under control.

To fully realize the potential effect of COVID-19 on your IBD, you first need to understand its stages. 
Rubin also emphasizes that this last phase mimics the overactive inflammatory phase of Crohn’s disease and ulcerative colitis. However, there’s greater risk for patients already on a steroid regimen. Growing research shows that if you’re on steroids you may have worse outcomes. “The issue regarding steroids and COVID-19 is based on when in the illness patients are on them,” Rubin says. Patients on doses greater than 20 milligrams per day at the time they get sick with COVID-19 have worse outcomes. “This is likely related to impaired early immunity but also perhaps [occurs] because patients on high-dose steroids have worse or poorly controlled IBD,” he says.   

Conversely, if the steroid use comes later, it may have some benefit. Rubin says some medications may actually reduce complications seen in COVID-19’s inflammatory phase. 
The 2002 and 2003 SARS-CoV-1 epidemic gave health care professionals and researchers a clearer picture of how the SARS-CoV-2 virus and the subsequent COVID-19 disease behaves in patients on a steroid regimen. “[Researchers] learned that steroids made the disease worse, and patients seemed to be more susceptible to complications from the virus when they were on steroids,” Rubin says. 

During SARS-CoV-1, steroids use resulted in slower clearance of the virus from the blood and even a higher rate of death. It’s important to note, however, that these outcomes weren’t just limited to those with IBD but extended to the general patient population. “Doctors tried treating patients with high doses of steroids; it didn’t work and seemed to make patients worse,” Rubin says. These outcomes and observations helped shape expert recommendations for IBD patients during the COVID-19 pandemic, too. 


More recently, health care professionals administered the steroid dexamethasone to hospitalized patients on oxygen and mechanical ventilation.
This randomized U.K. study found that those dexamethasone patients had better outcomes than those who didn’t receive the steroid. 

The main distinction between patients during the SARS-CoV-1 epidemic and the current pandemic: timing. Patient outcomes appear to depend on the phase in which individuals get treatment, Rubin says. The 2002–2003 epidemic reported worse outcomes when patients received steroids in the beginning stages of SARS-CoV-1; whereas, recent research has seen more success reducing inflammation at the later, more serious stage of COVID-19. 
People with IBD experience higher risks of COVID-19 complications if they suffer from ulcerative colitis or Crohn’s disease and have contributing factors like age, high blood pressure, diabetes or heart disease. “If you have more than two of those, you’re more at risk,” Rubin says. 

Recommendations if You Test Positive for COVID-19

Always consult with your health care team if you’ve been exposed to someone with COVID-19 and/or you develop symptoms. You need to discuss your treatment plan with your doctor and whether or not you need to quarantine.

If you test positive for SARS-CoV-2 but don’t exhibit symptoms, Rubin says the consensus recommendation from infectious disease experts and physicians is to work with your IBD treatment team to taper off steroids and other immunosuppressive therapies for two weeks. This will allow the body’s immune system to do its work and, hopefully, fight the virus off. 

Recommendation and Guidance from GI Societies

Treatment
Tested Positive (No Symptoms)
Covid-19 Symptoms
Treatment: Immunomodulators
Tested Positive (No Symptoms) Stop for 2 weeks; If COVID-19 has not developed, restart.
Covid-19 Symptoms Stop until fully recovered.
Covid-19 Symptoms Stop until fully recovered.
Treatment: Corticosteroids
Tested Positive (No Symptoms) Stop for 2 weeks; If COVID-19 has not developed, restart.
Covid-19 Symptoms Stop until fully recovered.
Covid-19 Symptoms Reduce or stop if possible and until fully recovered. Oral budesonide may be continued.
Treatment: Biologic/Biosimilar Therapies
Tested Positive (No Symptoms) Stop for 2 weeks; If COVID-19 has not developed, restart.
Covid-19 Symptoms Stop until fully recovered.
Covid-19 Symptoms Stop until fully recovered.
Treatment: Janus Kinase Inhibitors
Tested Positive (No Symptoms) Stop for 2 weeks; If COVID-19 has not developed, restart.
Covid-19 Symptoms Stop until fully recovered.
Covid-19 Symptoms Stop for 2 weeks; resume if symptoms improve.
Sources: Crohn's & Colitis Foundation; International Organization for the Study of Inflammatory Bowel Diseases; Rubin DT, et al. Gastroenterology, 2020; 159(1): 350-357. Rubin DT, et al. Gastroenterology, 2020; 159(1): 6-13.e6

Always consult with your healthcare provider before stopping or making changes with medications.
Always taper off any IBD therapies or medications under the care and observation of your health care team. “Even if some medicines are still in [your] system or [you were] on them in the early phase of the illness, [you] should be OK,” he says. 

If you do ultimately develop symptoms, the consensus recommendation is that you can restart medication three days after those symptoms go away However, Rubin stresses that you should check with your doctor to determine when you can safely restart any IBD medications.

How to Stay Engaged and Informed

To reduce your risk of contracting COVID-19, follow the Centers for Disease Control recommendations. And for more scientific-backed, timely information on increased risk factors you may face as an IBD patient, visit the Crohn’s & Colitis Foundation website. Among the many resources available here are how to safely navigate the workplace during the pandemic and what to do if you get sick as well as how to address the mental and emotional aspects as an IBD patient, some of whom may be at higher risk of complications from COVID-19 infection.
*Brenner EJ, Ungaro RC, Colombel JF, Kappelman MD. SECURE-IBD Database Public Data Update. covidibd.org. Accessed on 12/07/20.
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Crohn’s & Colitis Foundation can help you make sense of COVID-19 information and offer IBD patients the best guidance and resources for staying well.
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Current Recommendations

Drug Class
Medication Examples:
Continue Taking Medications?
Aminosalicylates
(Apriso™, Asacol®, Canasa®, Colazal®, Delzicol™, Lialda™, Pentasa®, Rowasa®)
YES. Take as prescribed.
Immunomodulators
Azathioprine (Azasan®, Imuran®, cyclosporine (Gengraf®, Neoral®, Sandimmune®), mercaptopurine (Purinethol®), methotrexate (Rheumatrex®), tacrolimus (Prograf®)
YES. Take as prescribed.
Biologics/Biosimilars
Anti-TNF biologics: adalimumab (Humira®), certolizumab pegol (Cimzia®), golimumab (Simponi®), infliximab (Remicade®), infliximab-abda (Renflexis®), infliximab-dyyb (Inflectra®), infliximab-qbtx (Xifi™). Integrin receptor antagonists: natalizumab (Tysabri®) and vedolizumab (Entyvio®), and interleukin 12 and 23 antagonists: ustekinumab (Stelara®)
YES. Take as prescribed.
JAK inhibitor
Tofacitinib (Xeljanz®)
YES. Take as prescribed.
Steroids
Budesonide (Entocort® EC, UCERIS™), methylprednisolone (A-Methapred®, Depo-Medrol®, Medrol Dosepak®, Solu-Medrol®), prednisolone (Orapred®, Pediapred®, Prelone®), prednisone (Deltasone®)
Do not adjust without talking to your doctor. Not generally recommended in high doses in IBD
Antibiotics
Examples:  Ciprofloxacin (Cipro®), Metronidazole (Flagyl®), Rifaximin (Xifaxan®) Vancomycin (Vancocin®)
YES. Take as prescribed.