Miguel Regueiro, MD: Ongoing Examination at Link Between Gastrointestinal Symptoms and COVID-19

When coronavirus disease 2019 (COVID-19) cases began to substantially rise in March, experts from virtually medical specialty began scrambling for data on how the virus might impact different internal systems.

Initially, many believe there was some gastrointestinal symptoms linked to infections, but in an interview with HCPLive®, Miguel Regueiro, MD, chair of the Department of Gastroenterology, Hepatology, and Nutrition at the Cleveland Clinic, explained how those symptoms are much more prevalent than originally thought.

HCPLive: What have we ultimately learned since we last spoke in early March in terms of the gastroenterological symptoms of COVID-19?

Regueiro: Obviously we keep learning every month, where something new comes. What we've learned in general is that the percentage of patients who have gastrointestinal symptoms is nearly two-thirds, much, much higher than we originally thought.

Now, we also have learned that there's still about 20% that will present only with GI symptoms. And interestingly, there have been some reports that some of these patients with only GI symptoms, really that's their main presentation. Meaning they don't go on to have those respiratory symptoms, they're more diarrhea, loss of taste and smell.

HCPLive: Do the gastrointestinal issues that present without the respiratory issues get as severe as some of the other manifestations of the virus?

Regueiro: The numbers are still small, but what we're actually seeing as some of these patients may not get the respiratory failure, but may get very bad fatigue, very bad flu-like symptoms. And yeah, it can be pretty severe, not ICU, but still some pretty significant symptoms.

HCPLive: I think it’s safe to say we don’t know a lot about this virus and why it impacts different people differently. Would figuring out what exactly triggers the disease differently in different people be the major breakthrough we need?

Regueiro: Absolutely 100%. Things that have been looked at is male versus female, different ethnicities, different blood types. The problem is that it is vague enough that we don't know enough to lead us down that precision path.

If we had the precision medicine and the predictors of COVID-19 that says one person goes down the path of being really sick and needing to go to ICU and being on a ventilator, then maybe we started antiviral therapy a lot earlier. Is the other path of GI leading to a set of different symptoms that we learn that maybe they respond to different therapy?

HCPLive: There have been recent reports of permanent lung damage seen for COVID-19 patients. Are we seeing anything concerning regarding some permanent gastrointestinal symptoms?

Regueiro: So, they're worried about inflammation that leads to scarring in the lungs, and that's permanent. In the GI tract, the things that we’re wondering could be permanently changes is the microbiome. The bacteria makeup in the gut, is it somehow shifting people and that’s why they’re getting more diarrhea or bloating or cramps or pain.

The other thing is that there's clearly evidence of what we call ischemic colitis. So, the blood vessels in the GI tract get inflamed and there’s poor blood flow to the colon, the gastrointestinal tract. Those people are they set up for other problems down the line?

So, whether it be some type of colitis or some inflammatory condition, are they going to have more diarrhea, pain? Absolutely likely.

HCPLive: Have we had any success testing the IBD drugs for efficacy against COVID-19?

Regueiro: We're still learning about it. Those drugs for IBD like low-dose steroids, dexamethasone, the anti-TNF agent tofacitinib. That's all being discussed and researched.

Those are treating more of what we call the cytokine storm. The immune system's reaction to the virus that these drugs actually tamp down to improve inflammation. Those are in the discovery phase, so I don’t think we have enough information that we can say conclusively.

HCPLive: Have we learned whether IBD patients are more susceptible to some of the more severe outcomes?

Regueiro: We’ve learned a lot more and the fortunate answer is they don’t seem to have a worse course. This SECURE-IBD registry is a worldwide registry of patients that we entered that have known Crohn’s or ulcerative colitis and then they get COVID-19.

We have good and expanding data on that and so far it seems that the incidence and prevalence of somebody getting COVID-19 doesn’t seem any different whether you’re on IBD medications or immunosuppression compared to someone who’s not.

Our IBD patients had a slightly lower prevalence. Our IBD patients are more careful anyway. They practice more careful hygiene, social distancing to some degree, kind of very cautious in what they do.