COVID-19 and Outcomes in Patients With Inflammatory Bowel Disease: Systematic Review and Meta-Analysis

Abstract

Background Our understanding of coronavirus disease 2019 (COVID-19) and its implications for patients with inflammatory bowel diseases (IBD) is rapidly evolving. We performed a systematic review and meta-analysis to investigate the epidemiology, clinical characteristics, and outcomes in IBD patients with COVID-19. Methods We searched PubMed, EMBASE, Cochrane Central, Clinicaltrials.gov, Web of Science, MedRxiv, and Google Scholar from inception through October 2020. We included studies with IBD patients and confirmed COVID-19. Data were collected on the prevalence, patient characteristics, pre-infection treatments for IBD, comorbidities, hospitalization, intensive care unit (ICU), admission, and death. Results Twenty-three studies with 51,643 IBD patients and 1449 with COVID-19 met our inclusion criteria. In 14 studies (n = 50,706) that included IBD patients with and without COVID-19, the prevalence of infection was 1.01% (95% confidence interval [CI], 0.92-1.10). Of IBD patients with COVID-19, 52.7% had Crohn’s disease, 42.2% had ulcerative colitis, and 5.1% had indeterminate colitis. Nine studies (n = 687) reported outcomes according to IBD therapy received. Compared with patients on corticosteroids, those on antitumor necrosis factor (anti-TNF) therapy had a lower risk of hospitalization (risk ratio [RR], 0.24; 95% CI, 0.16-0.35; P < .01; I2 = 0%) and ICU admission (RR, 0.10; 95% CI, 0.03-0.37; P < .01) but not death (RR, 0.16; 95% CI, 0.02-1.71; P = .13; I2 = 39%). Compared with patients on mesalamine, those on antitumor necrosis factor therapy had a lower risk of hospitalizations (RR, 0.37; 95% CI, 0.25-0.54), ICU admissions (RR, 0.20; 95% CI, 0.07-0.58), and death (0.21; 95% CI, 0.04-1.00). Comparing patients on immunomodulators vs mesalamine or anti-TNF therapy, there was no difference in these outcomes. Conclusions The prevalence of COVID-19 in IBD patients was low. Use of corticosteroids or mesalamine was significantly associated with worse outcomes, whereas use of anti-TNFs was associated with more favorable outcomes. Further investigation clarifying the mechanisms of these disparate observations could help identify risk and adverse outcome-mitigating strategies for patients with IBD.

Recent advances in clinical practice: management of inflammatory bowel disease during the COVID-19 pandemic

“…In one meta-analysis, pooled relative risks of hospitalisation (RR 0.34, 95% CI 0.19 to 0.61), ICU admission (RR 0.49, 95% CI 0.33 to 0.72) and mortality (RR 0.22, 95% CI 0.13 to 0.38) were lower in biological-treated patients, most of whom were on anti-TNF, compared with patients treated with other non-biologicals for IBD 30. A meta-analysis also found that patients treated with anti-TNF therapy had decreased risk of hospitalisation and ICU admission compared with corticosteroids or 5-ASA 56…”

“…Conflicting results have been reported on the effect of 5-aminosalicylic acid (5-ASA) on the disease course of COVID-19 in patients with IBD. Several studies conducted early in the pandemic, including two meta-analyses, demonstrated an increased risk of critical care, ventilator use and mortality in those treated with 5-ASA compared with those not treated with 5-ASA 34 35 56. For instance, pooled relative risks was 1.59 for hospitalisation (95% CI 1.39 to 1.82), 2.38 for ICU admission (95% CI 1.26 to 4.48) and 2.62 for mortality (95% CI 1.67 to 4.11) in patients treated with 5-ASA 30.…”

“…Some studies suggest that the risk of developing severe COVID-19 may be lower in biological-treated patients potentially due to the effect of these drugs in suppressing cytokine inflammatory pathways that underlie COVID-19-associated inflammatory complications 30 56 59. In one meta-analysis, pooled relative risks of hospitalisation (RR 0.34, 95% CI 0.19 to 0.61), ICU admission (RR 0.49, 95% CI 0.33 to 0.72) and mortality (RR 0.22, 95% CI 0.13 to 0.38) were lower in biological-treated patients, most of whom were on anti-TNF, compared with patients treated with other non-biologicals for IBD 30.…”

Long COVID in Inflammatory Bowel Diseases

“…Unfortunately, however, the use of these therapies has been associated with an increased risk for bacterial and viral infections and viral reactivation [ 12 ]. Several authors have investigated the epidemiology, clinical characteristics, and outcomes in IBD patients with COVID-19, and a recent systematic review and meta-analysis of 14 studies including 50706 IBD patients with and without COVID-19 reported a low prevalence of COVID-19 in IBD patients and a worse outcome of COVID-19 in IBD patients receiving corticosteroids or mesalamine, while the use of anti-TNFs was associated with more favorable outcomes [ 13 ]. In contrast, there is no data about the prevalence and impact of Long COVID in IBD.…”

Impact of COVID-19 in Pediatric Patients and Young Adults with Inflammatory Bowel Disease

“…The cumulative experience of the last 2 years is in favor of continuing ongoing IBD therapy and not delaying the beginning of conventional immunomodulators or biological therapy because of the pandemic situation, in patients without COVID-19 [ 19 , 20 ].…”