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

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.