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Abstract

We appreciate the positive response from Dr Carlos Taxonera and colleagues1Taxonera C. et al.Gastroenterology. 2021; 160: 1899-1900Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar regarding our epidemiological study on rates of Coronavirus Disease 2019 (COVID-19) among patients with inflammatory bowel disease (IBD).2Gubatan J. et al.Gastroenterology. 2020; 159: 1141-1144.E2Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Our results, based on our experience in Northern California during the early days of the COVID-19 pandemic (March 4, 2020, to April 14, 2020), suggested that the prevalence of COVID-19 among patients with IBD was comparable with the general population.2Gubatan J. et al.Gastroenterology. 2020; 159: 1141-1144.E2Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Since our study, much data have rapidly accumulated to overcome sample size limitations and enabled us to expand and refine our understanding of the risks of COVID-19 among patients with IBD both at the national level and on a global scale. In a retrospective, multicenter research network study (data collected from January 20, 2020, and May 26, 2020) in the United States involving more than 40 million patients from multiple health care organizations, Singh et al3Singh S. et al.Gastroenterology. 2020; 159: 1575-1578Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar reported COVID-19 in 232 patients with IBD and 19,776 patients without IBD. In unadjusted analysis, there was no difference in the risk of severe COVID-19 between the IBD and non-IBD groups (risk ratio [RR], 1.15; 95% CI, 0.92–1.45; P = .23). After propensity score matching, the risk of severe COVID-19 was similar (RR 0.93; 95% CI, 0.68–1.27; P = .66) between both groups.3Singh S. et al.Gastroenterology. 2020; 159: 1575-1578Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar In the same study, immune-mediated therapy in the preceding year was not associated with a higher risk of severe COVID-19 compared with patients with IBD not on immune-mediated therapy. However, preceding corticosteroid use was associated with an increased risk of severe COVID-19 compared with patients with IBD without corticosteroids. In a systematic review (up to July 29, 2020) and meta-analysis of 23 studies including 243,760 patients with IBD, D’Amico et al4D’Amico F. et al.Clin Gastroenterol Hepatol. 2020; 18: 2689-2700Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar reported COVID-19 in 1028 patients with IBD (49.5% with Crohn’s disease, 41.6% with ulcerative colitis) resulting in a cumulative prevalence of 0.4%. Increasing age and the presence of comorbidities were recognized as risk factors for COVID-19 and negative clinical outcomes. In another systematic review and meta-analysis (December 2019 to July 2020) by Singh et al5Singh A.K. et al.United European Gastroenterology. 2020; Google Scholar including 24 studies (patient cohorts from the United States, Spain, Iran, Italy, France, Germany, Greece, China, South Korea, Hong Kong, Taiwan, and the international registry SECURE-IBD), the pooled incidence rate of COVID-19 in patients with IBD was 4.02 (95% CI, 1.44–11.17; I2 = 98%) per 1000, whereas the pooled rate of COVID-19 in the general population was 6.59 (95% CI, 3.25–13.35; I2 = 100%) per 1000. The pooled relative risk of COVID-19 in patients with IBD was not different from the general population (relative risk 0.47; 95% CI, 0.18–1.26; I2 = 89). We agree with Taxonera et al1Taxonera C. et al.Gastroenterology. 2021; 160: 1899-1900Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar that the impact of IBD therapies on risks of COVID-19 infection acquisition and progression warrants further investigation, as immunosuppressive drugs have been linked with risk of infection in IBD.6Bonovas S. et al.Clin Gastroenterol Hepatol. 2016; 10: 1385-1397Abstract Full Text Full Text PDF Scopus (243) Google Scholar In the meta-analysis by Singh et al,5Singh A.K. et al.United European Gastroenterology. 2020; Google Scholar only 5-aminosalicylic acid (5-ASA) use was associated with increased risk of COVID-19 (relative risk 1.89; 95% CI, 1.23–2.93; I2 = 37%). Furthermore, 5-ASA and steroid use were associated with increased risk of COVID-19 inpatient hospitalizations, intensive care unit admissions, and mortality, whereas there were no significant associations with immunomodulators and biologic therapies.5Singh A.K. et al.United European Gastroenterology. 2020; Google Scholar In an analysis of the SECURE-IBD registry (1439 cases from 47 countries), Ungaro et al7Ungaro R. et al.Gut. 2020 Oct 20; ([Epub ahead of print])PubMed Google Scholar demonstrated that mesalamine (5-ASA) use was associated with severe COVID-19 compared with no 5-ASA use or anti–tumor necrosis factor monotherapy as reference groups. The authors also demonstrated that thiopurine monotherapy and the combination thiopurines with anti–tumor necrosis factor agents were associated with significantly increased risk of severe COVID-19.6Bonovas S. et al.Clin Gastroenterol Hepatol. 2016; 10: 1385-1397Abstract Full Text Full Text PDF Scopus (243) Google Scholar Further studies will be needed to understand the mechanisms of how 5-ASA and steroids may confer risk of COVID-19 infection and how thiopurines may modulate COVID-19 severity in patients with IBD. Although biologic therapies have not been linked to COVID-19 susceptibility and severity in IBD, a recent study demonstrated that patients with immune-mediated inflammatory diseases receiving cytokine inhibitors have low prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroconversion.8Simon D. et al.Nat Commun. 2020; 11: 1-7Crossref PubMed Scopus (58) Google Scholar Future studies investigating the ability of patients with IBD on immunosuppressive drugs to develop robust, longstanding immunity against SARS-COV-2 after natural infection or vaccination are warranted. In conclusion, cumulative evidence to date support our original finding that the risk of COVID-19 in patients with IBD is comparable with the general population.2Gubatan J. et al.Gastroenterology. 2020; 159: 1141-1144.E2Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Future shift in focus toward understanding the incidence of protective SARS-CoV-2 antibodies in patients with IBD on different therapies in light of the increasing number of patients recovering from COVID-19 and the expanding availability of COVID-19 vaccines would be highly valuable. What Is the Incidence of COVID-19 in Patients With IBD in Western Countries?GastroenterologyVol. 160Issue 5PreviewWe read with interest the article by Gubatan et al1 reporting that, among 168 patients with inflammatory bowel disease (IBD) tested in Northern California (Stanford University School of Medicine), the prevalence of coronavirus disease 2019 (COVID-19) was 3.0%, comparable with the population-weighted prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–positive serology in Santa Clara County at 2.8%. The authors concluded that their results provided much-needed epidemiologic data and reassurance that COVID-19 rates in patients IBD may be comparable with that in the general population. Full-Text PDF