Treatment Adaptations and Outcomes of Patients Experiencing Inflammatory Bowel Disease Flares During the Early COVID-19 Pandemic

The PREPARE-IBD Multicentre Cohort Study

Aamir Saifuddin; Alexandra J. Kent; Shameer J. Mehta; Lucy C. Hicks; Haidee A. Gonzalez; Jonathan P. Segal; Matthew J. Brookes; Sreedhar Subramanian; Neeraj Bhala; Thomas E. Conley; Kamal V. Patel; Christopher A. Lamb; Gareth J. Walker; Nicholas A. Kennedy; Shaji Sebastian

Disclosures

Aliment Pharmacol Ther. 2022;56(10):1460-1474. 

In This Article

Abstract and Introduction

Abstract

Background: The COVID-19 pandemic offered a unique opportunity to understand inflammatory bowel disease (IBD) management during unexpected disruption. This could help to guide practice overall.

Aims: To compare prescribing behaviour for IBD flares and outcomes during the early pandemic with pre-pandemic findings

Methods: We performed an observational cohort study comprising patients who contacted IBD teams for symptomatic flares between March and June 2020 in 60 National Health Service trusts in the United Kingdom. Data were compared with a pre-pandemic cohort after propensity-matching for age and physician global assessment of disease activity.

Results: We included 1864 patients in each of the pandemic and pre-pandemic cohorts. The principal findings were reduced systemic corticosteroid prescription during the pandemic in Crohn's disease (prednisolone: pandemic 26.5% vs. 37.1%; p < 0.001) and ulcerative colitis (UC) (prednisolone: pandemic 33.5% vs. 40.7%, p < 0.001), with increases in poorly bioavailable oral corticosteroids in Crohn's (pandemic 15.6% vs. 6.8%; p < 0.001) and UC (pandemic 11.8% vs. 5.2%; p < 0.001). Ustekinumab (Crohn's and UC) and vedolizumab (UC) treatment also significantly increased. Three-month steroid-free remission in each period was similar in Crohn's (pandemic 28.4% vs. 32.1%; p = 0.17) and UC (pandemic 36.4% vs. 40.2%; p = 0.095). Patients experiencing a flare and suspected COVID-19 were more likely to have moderately-to-severely active disease at 3 months than those with a flare alone.

Conclusions: Despite treatment adaptations during the pandemic, steroid-free outcomes were comparable with pre-pandemic levels, although concurrent flare and suspected COVID-19 caused worse outcomes. These findings have implications for IBD management during future pandemics and for standard practice.

Introduction

Crohn's disease and ulcerative colitis (UC) represent the two principal forms of inflammatory bowel disease (IBD). Both are characterised by mucosal and extraintestinal immune dysregulation. Given that the cornerstone of treatment involves effective immune suppression, it became clear early in the coronavirus infectious disease (COVID)-19 pandemic that IBD clinicians' normal practice may become disrupted, with potential effects on patient outcomes.[1] While conventional pre-pandemic treatment paradigms are effective at inducing disease remission in IBD, many therapies are associated with an increased risk of infections requiring hospitalisation and/or development of opportunistic infections, in particular, thiopurines and tofacitinib.[2] The immune suppressive effects of many of these drugs may last for weeks or months following treatment discontinuation, with international guidelines advising intervals of up to 6 months before administering live vaccines.[3] Even in the absence of immune-directed treatments, IBD patients have a higher seasonal influenza risk and are more likely to be hospitalised.[4] High dose corticosteroids and uncontrolled IBD disease activity are now important risk factors for severe COVID-19 infection and many clinicians harboured grave concerns regarding the safety of immunosuppressive therapies during the start of the pandemic.[5–7] It is unknown if this translated to modification of IBD flare management strategies and if subsequent disease outcomes were impacted. Thus, the onset of the COVID-19 pandemic offered a unique opportunity to observe the consequences of perturbations to conventional healthcare pathways.

In March 2020, we established the multicentre cohort "Physician Responses to disease flares and Patient Adaptation in Relation to Events in Inflammatory Bowel Disease during the COVID-19 pandemic (PREPARE-IBD)". We collated data relating to management of active disease during the first wave of the pandemic from across the UK and compared these with a pre-pandemic control group. We assessed how treatment behaviour changed during this challenging period and the subsequent impact on 3-month outcomes to guide future practice within and outside of a pandemic setting.

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