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This has been reviewed and updated as of May 29, 2020.
Living with inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis, has its own set of challenges, but what does it mean in light of the COVID-19 pandemic? The expert answers to the following questions should help clear things up.
Are IBD Patients Considered Immunosuppressed?
The answer may depend on your current level of disease activity.
According to the American College of Gastroenterology (ACG), simply having Crohn’s disease or ulcerative colitis does not raise your risk of COVID-19, but certain related factors might.
“IBD is a condition in which the immune system is in a dysregulated state,” which means that it malfunctions in a way that makes it difficult to control inflammation in the intestines, says gastroenterologist Ryan Ungaro, MD, assistant professor at The Susan and Leonard Feinstein IBD Center at the Icahn School of Medicine at Mount Sinai in New York City. “But we don’t think that IBD in and of itself is a major risk factor for viral infections like COVID-19.”
Inflammatory bowel disease patients whose condition is not well-controlled, however, may very well face an increased risk, says Bradley Morganstern, MD, co-director of the IBD Center at Stony Brook Medicine in Stony Brook, New York.
“If there is too much immune activity in the gut, there might not be enough elsewhere in the body,” he explains. He adds that people with IBD who are not properly treated may be malnourished, which could, in turn, make them more susceptible to catching a viral infection such as COVID-19.
It is also important to note that many medications that are commonly used to treat IBD can suppress the immune system, so patients who take them may be considered immunosuppressed.
A recent case series published in the New England Journal of Medicine found that compared to the general population, people with autoimmune conditions (including inflammatory bowel disease as well as psoriasis, rheumatoid arthritis, and psoriatic arthritis) had a lower rate of hospitalization during the pandemic so far. This patient population was more apt to be hospitalized if they had co-occurring high blood pressure, diabetes, or chronic obstructive pulmonary disease (COPD). What’s more, the researchers determined that “baseline use of biologics [in people with autoimmune disease] is not associated with worse COVID-19 findings.” Read more here about the preliminary research.
A study recently published in the journal Gastroenterology reached a similar conclusion. That research focused on IBD patients in Spain who tested positive for COVID-19. The authors found that they had “a good overall prognosis.” Half needed to be hospitalized, but none were admitted to the ICU or put on a ventilator.
Based on what is known right now, age and comorbidities seem to be bigger influences on poor outcomes from COVID-19 than having an inflammatory condition alone.
Which IBD Medications Suppress the Immune System?
Many Crohn’s disease or ulcerative colitis patients take medications that fall into one of four main categories: steroids, aminosalicylates, immunomodulators, and biologics. Here is more information on how each affects the immune system.
These drugs (such as prednisone and budesonide) suppress the immune system when taken orally. “We think taking steroids is the biggest risk factor for infection” among IBD patients, says Dr. Ungaro. He adds that COVID-19 patients who have been treated with high-dose steroids ended up getting sicker.
A new report, published in the journal Gastroenterology, found that IBD patients who use steroid medication are more apt to develop complications of COVID-19 compared to those who don’t use these drugs.
Read more here about steroids and coronavirus risk.
Drugs like mesalamine and sulfasalazine work to inhibit inflammation in the gut. They may be given orally or topically (via enemas or suppositories), but either way are not believed to raise the risk of infections.
These drugs, which include azathioprine, 6-MP, methotrexate, cyclosporine, and tacrolimus, suppress the body’s immune response. That’s useful for controlling an over-active immune response that causes inflammation in the gut, but it can also raise your risk of certain infections. Read more here about methotrexate and coronavirus risk.
There is not yet enough data to know how these medications are affecting COVID-19 risk specifically.
Biologic drugs — including TNF inhibitors like infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira); interleukin inhibitors like ustekinumab (Stelara); and vedolizumab (Entyvio), which is an anti-integrin drug — certainly suppress the immune system to a certain extent, but they are more targeted and therefore less likely than steroids and immunomodulators to raise your risk of infections, says Dr. Ungaro. Vedolizumab is the least risky of the biologics in terms of infection risk because its mechanism of action is fairly limited to the gut, he says.
Some IBD patients use a small-molecule drug (known as a JAK inhibitor) called tofacitinib (Xeljanz), which is similar to most biologics in terms of infection risk.
Should You Stop Taking Your IBD Medication?
First of all, do not make any changes to your medication regimen without first talking to your doctor.
According to the ACG, keeping IBD well-controlled or in remission may help protect you from contracting COVID-19.
“Right now the real hotspots for spread of this infection are in health care settings,” says Dr. Ungaro. If your condition is well-controlled and you stop taking your usual medications, you risk having a flare. “We do not want patients to have a flare in the midst of this pandemic and end up in the ER where they could be exposed [to COVID-19].”
If you’re using steroids: Topical steroids, which are taken via suppositories or enemas, are unlikely to cause problems. Systemic (oral) steroids, however, are another story. “If you’re on oral steroids, now is a good time to start tapering off them if you can,” says Dr. Ungaro, but do not stop taking steroids cold turkey. Call your gastroenterologist, discuss whether it is a good idea for you to start decreasing your dose, and find out how to do so slowly and safely.
If you’re using aminosalicylates, biologics, or immunomodulators: If you’re doing well on a drug in one of these classes, stick with it, says Dr. Morganstern. “If you stop, you’re at risk of flaring.”
One exception, however, may be for patients who are stable and taking both an immunomodulator and a biologic. “If someone is in remission on combination therapy, I might try removing the immunomodulator” and keeping the biologic, says Dr. Morganstern.
If you develop COVID-19 symptoms or have direct exposure to someone with symptoms or a confirmed diagnosis, however, this advice may change. See more below.
How Can You Reduce Your Chances of Getting COVID-19?
If you have Crohn’s disease or ulcerative colitis, consider that you could be immunosuppressed at least to a certain degree. You should be practicing social distancing to the fullest extent that you can.
“Ideally, stay home and let someone else do the food shopping,” says Dr. Morganstern. You should also be extra strict about good hand hygiene, wearing a face mask in public places, and regularly disinfecting commonly used surfaces in your home.
Dr. Ungaro adds that this is a stressful time for everyone, and that many IBD patients report that their symptoms get worse when they’re stressed — even if blood tests don’t always show that inflammation has increased.
“There is a very strong brain/gut connection,” he says. “It’s normal to have anxiety, but if you can do something proactive about it — like connect with a psychologist or social worker through telemedicine — it’s a good idea.”
You can also try to exercise more at home, download and use a meditations app, or do anything else that helps you unwind. You can get mental health advice for coping with coronavirus-related anxiety and other issues through our GHLF Patient Support Program.
Should You Get a Colonoscopy During the Pandemic?
Many IBD patients get a colonoscopy every year or two to keep tabs on their symptoms. If you’re due for one, is it safe at this time? According to a new review, published in the journal Lancet Gastroenterology & Hepatology, IBD patients and their providers need to weigh the pros of accurate disease monitoring against the risks of possible exposure to COVID-19.
The authors advise that most IBD patients should postpone routine colonoscopies, but that there are certain circumstances in which it is wiser not to delay. For instance, someone who has symptoms of a bowel obstruction or is experiencing bleeding and other symptoms of severe acute colitis likely needs to have a colonoscopy as soon as possible. A person who develops IBD symptoms for the first time might also need a colonoscopy in order to get the correct diagnosis.
What If You Have IBD and Develop COVID-19 Symptoms?
If you develop symptoms that could be COVID-19, call your gastroenterologist. The most common symptom of COVID-19 is fever, which often goes hand-in-hand with a dry cough and shortness of breath. Here is a list of other common COVID-19 symptoms.
“If someone develops COVID symptoms, we might hold their medications until symptoms resolve,” says Dr. Morganstern. “We often do that when someone gets an infection in general, especially if it involves a fever.” Follow your doctor’s or public health department’s advice for managing COVID-19 at home with supportive care, such as acetaminophen to treat fever, and make sure you know when to seek additional medical attention for worsening symptoms.
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American College of Gastroenterology Inflammatory Bowel Disease and COVID-19 Patient Information. American College of Gastroenterology. March 23, 2020. https://webfiles.gi.org/links/patients/COVID19_IBD_ACG_Patient_Handout_03232020_FINAL.pdf.
Brenner EJ, et al. Corticosteroids, but Not TNF Antagonists, Are Associated With Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases. Gastroenterology. May 8, 2020. doi: https://doi.org/10.1053/j.gastro.2020.05.032.
Coronavirus (COVID-19): What IBD Patients Should Know. Crohn’s & Colitis Foundation. https://www.crohnscolitisfoundation.org/coronavirus/what-ibd-patients-should-know.
Haberman R, et al. Covid-19 in Immune-Mediated Inflammatory Diseases — Case Series from New York. New England Journal of Medicine. April 29, 2020. doi: https://doi.org/10.1056/NEJMc2009567.
Iacucci M, et al. Endoscopy in Inflammatory Bowel Diseases During the COVID-19 Pandemic and Post-Pandemic Period. The Lancet Gastroenterology & Hepatology. April 16, 2020. doi: https://doi.org/10.1016/S2468-1253(20)30119-9.
Inflammatory Bowel Disease (IBD). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/inflammatory-bowel-disease/symptoms-causes/syc-20353315.
Interview with Bradley Morganstern, MD, gastroenterologist and co-director of the IBD Center at Stony Brook Medicine in Stony Brook, New York
Interview with Ryan Ungaro, MD, gastroenterologist and assistant professor at The Susan and Leonard Feinstein IBD Center at the Icahn School of Medicine at Mount Sinai in New York City
Resources for IBD Healthcare Professionals: 2019 Novel Coronavirus (COVID-19). Crohn’s & Colitis Foundation. https://www.crohnscolitisfoundation.org/coronavirus/professional-resources.
Rodríguez-Lago I, et al. Characteristics and Prognosis of Patients with Inflammatory Bowel Disease During the SARS-CoV-2 Pandemic in the Basque Country (Spain). Gastroenterology. April 16, 2020. doi: https://doi.org/10.1053/j.gastro.2020.04.043.
Symptoms of Coronavirus. U.S. Centers for Disease Control and Prevention.
What is inflammatory bowel disease (IBD)? Centers for Disease Control and Prevention. https://www.cdc.gov/ibd/what-is-IBD.htm.