Corticosteroid Use Linked to Increased Risk of Hospitalization, Ventilation in IBD Patients with COVID-19

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Patients receiving systemic corticosteroids faced an increased risk of severe COVID-19 requiring hospitalization or mechanical ventilation compared to other medication classes used to treat IBD.

Michael D. Kappelman, MD, MPH | Credit: UNC School of Medicine

Michael D. Kappelman, MD, MPH

Credit: UNC School of Medicine

Findings from a retrospective cohort study of more than 100,000 patients with inflammatory bowel disease (IBD) linked treatment with systemic corticosteroids to increased rates of inpatient admission and ventilator use associated with COVID-19.

“As fears of infectious complications surrounding immunosuppressive medication use can lead to cessation or interruption in therapy, these data inform a critical gap for patients,” wrote investigators.1

The US Centers for Disease Control and Prevention estimate 3.1 million adults in the US have IBD, a condition linked with immune system malfunction causing inflammation of the gastrointestinal tract.2,3 With use of immunosuppressive medications, such as biologics, corticosteroids, and immunomodulators, common among these patients, an understanding of potential increase in risk for COVID-19 stands to benefit both patients and clinicians.4

A team of investigators led by Michael D. Kappelman, MD, MPH, professor of Pediatric Gastroenterology at University of North Carolina Chapel Hill, calculated the risk of COVID-19 complications in individuals with IBD using insurance claims data from 2 large US health plans participating in the US Food and Drug Administration Sentinel System. Using patient data from Anthem and Humana, investigators obtained data related to a cohort of 102,986 patients with IBD.1

For the purpose of analysis, March 1, 2020 was used as the cohort entry date. The overall study period lasted from August 31, 2019-August 31, 2021.1

The primary outcomes of interest for the study included COVID-19 hospitalization, mechanical ventilation, and inpatient death. Different medication classes used in treatment of IBD were used as exposures of interest. Investigators pointed out participants were followed until first occurrence of a study outcome outpatient death, loss of medical coverage, or end of available data.1

Of the 102,986 patients identified for inclusion, 25,538 were receiving no pharmacologic treatments, 16,868 were receiving anti TNF inhibitors, and 11,189 were receiving systemic corticosteroids.1

Among the study cohort, 419 (0.4%) patients were hospitalized due to COVID-19. Compared to those who were not hospitalized due to COVID-19, patients hospitalized had a greater mean age (53.3 vs 68.1 years; P < .001), were more likely to be obese (16% vs 28%; P < .001), and have a history of chronic kidney disease (19% vs 45%; P < .001) or cardiovascular disease (8% vs 30%; P < .001).1

Initial analysis indicated an increased risk for inpatient admission (13.6 per 1000 person-years; 95% CI, 10.8-17.0) and ventilation (3.9 per 1000 person-years; 95% CI, 2.5-5.9) was observed with systemic corticosteroid use relative to no medication use. Compared to systemic corticosteroid use, use of TNF inhibitors was associated with a reduced risk of hospitalization (3.9 per 1000 person-years; 95% CI, 2.7-5.4) and requiring ventilation (0.6 per 1000 person-years; 95% CI, 0.2-1.3). Of note, sex, age, and comorbidities were comparable among participants using corticosteroid and other classes of immunosuppressive medications, but rates of smoking were higher (23%) among corticosteroid users.1

Investigators were unable to perform multivariate analyses due to the aggregate nature of available data, instead conducting additional analyses within various strata. In these analyses, investigators identified older age (P < .001) and multiple comorbidities such as obesity (P < .001) as additional risk factors for hospitalization. Additionally, inpatient admission was stratified by age group. Investigators pointed out rates were notably higher for the group ≥65 years of age across each medication class and the majority of ventilation cases (72%) as well as COVID-19-related deaths (85%) occurred among patients aged 65 years or more.1

“There are a number of implications to this study, namely that controlling disease activity and utilizing steroid-sparing therapy in the management of IBD remains an important tenet of patient care during the COVID-19 pandemic. These data show that corticosteroid use, particularly in older individuals, is associated with a much higher risk of severe COVID-19 than other classes of medications, such as biologic therapies. Therefore, optimizing noncorticosteroid therapies to induce and maintain remission should be prioritized in IBD management,” concluded investigators.1

References

  1. Long MD, Parlett L, Lewis JD, et al. Corticosteroids but not anti-TNF are associated with increased COVID-19 complications in patients with inflammatory bowel disease. Inflammatory Bowel Diseases. Published online 2023. doi:10.1093/ibd/izad176
  2. People with IBD have more chronic diseases. Centers for Disease Control and Prevention. April 15, 2022. https://www.cdc.gov/ibd/features/IBD-more-chronic-diseases.html.
  3. What is inflammatory bowel disease (IBD)? Centers for Disease Control and Prevention. April 13, 2022. Accessed August 24, 2023. https://www.cdc.gov/ibd/what-is-IBD.htm#:~:text=The%20exact%20cause%20of%20IBD,to%20be%20a%20genetic%20component.
  4. Inflammatory bowel disease: Symptoms, treatment & diagnosis. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/15587-inflammatory-bowel-disease-overview.
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