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Diarrhea prevalent among COVID-19 patients with IBD

Key clinical point: Among patients with COVID-19, inflammatory bowel disease (IBD) was associated with a markedly increased prevalence of diarrhea.

Major finding: Fully 20.5% of patients with IBD and COVID-19 had diarrhea, at least twice the prevalence seen with pooled data from prior studies.

Study details: Systematic review and meta-analysis of 23 studies incorporating data from 449 patients with IBD and COVID-19.

Disclosures: No funding sources were disclosed. Dr. D’Amico reported having no conflicts of interest. Two coinvestigators disclosed ties to AbbVie, MSD, Schering-Plough, UCB Pharma, and several other pharmaceutical companies.

Citation:

D’Amico F et al. Clin Gastroenterol Hepatol. 2020 Aug 7. doi: 10.1016/j.cgh.2020.08.003.

Commentary:

Diarrhea is one of the hallmark features in inflammatory bowel disease (IBD). The systematic review and meta-analysis by D’Amico and colleagues highlights an increased prevalence of diarrhea in IBD patients with COVID-19. We have learned that SARS-CoV-2 enters the gastrointestinal tract through angiotensin converting enzyme 2, which has been found in absorptive enterocytes of the ileum and colon. The subsequent invasion can cause a change in intestinal microbiota (dysbiosis) and trigger diarrhea. Prior studies also reported SARS-CoV-2 being isolated in the duodenum and rectum while showing RNA shedding in approximately 40% of patients. Clinicians may now face the diagnostic challenge of distinguishing the cause of diarrhea as an exacerbation from underlying IBD versus viral superinfection. The authors astutely hypothesized that having access to fecal polymerase chain reaction tests may be particularly useful to guiding clinical treatment decisions.

The study further showed that the mortality rate in IBD patients with COVID-19 (3.8%) was lower, compared with the general population (approximately 10%). This is a similar trend observed in the international SECURE-IBD database, which now includes more than 2,500 patients worldwide. Importantly, IBD patients who are elderly, have multiple comorbidities, or are on high-dose corticosteroids were most at risk of severe COVID outcomes, including intensive care admission and death. Ultimately, this meta-analysis along with expert consensus statements from organizations like the International Organization For the Study of Inflammatory Bowel Disease and the American Gastroenterology Association, demonstrate that IBD patients (including those on biologic treatments) were not at higher risk of contracting COVID-19, compared with the non-IBD population. These findings should encourage IBD patients and clinicians to continue maintenance biologic and immunosuppressant treatments.

Lukasz Kwapisz, MD, FRCPC, is assistant professor of medicine and gastroenterology at Baylor College of Medicine, Houston. He has no conflicts of interest.