COVID-19 and Outcomes in Patients With Inflammatory Bowel Disease: Systematic Review and Meta-Analysis

Background Our understanding of coronavirus disease 2019 (COVID-19) and its implications for patients with inflammatory bowel diseases (IBD) is rapidly evolving. We performed a systematic review and meta-analysis to investigate the epidemiology, clinical characteristics, and outcomes in IBD patients with COVID-19. Methods We searched PubMed, EMBASE, Cochrane Central, Clinicaltrials.gov, Web of Science, MedRxiv, and Google Scholar from inception through October 2020. We included studies with IBD patients and confirmed COVID-19. Data were collected on the prevalence, patient characteristics, pre-infection treatments for IBD, comorbidities, hospitalization, intensive care unit (ICU), admission, and death. Results Twenty-three studies with 51,643 IBD patients and 1449 with COVID-19 met our inclusion criteria. In 14 studies (n = 50,706) that included IBD patients with and without COVID-19, the prevalence of infection was 1.01% (95% confidence interval [CI], 0.92-1.10). Of IBD patients with COVID-19, 52.7% had Crohn’s disease, 42.2% had ulcerative colitis, and 5.1% had indeterminate colitis. Nine studies (n = 687) reported outcomes according to IBD therapy received. Compared with patients on corticosteroids, those on antitumor necrosis factor (anti-TNF) therapy had a lower risk of hospitalization (risk ratio [RR], 0.24; 95% CI, 0.16-0.35; P < .01; I2 = 0%) and ICU admission (RR, 0.10; 95% CI, 0.03-0.37; P < .01) but not death (RR, 0.16; 95% CI, 0.02-1.71; P = .13; I2 = 39%). Compared with patients on mesalamine, those on antitumor necrosis factor therapy had a lower risk of hospitalizations (RR, 0.37; 95% CI, 0.25-0.54), ICU admissions (RR, 0.20; 95% CI, 0.07-0.58), and death (0.21; 95% CI, 0.04-1.00). Comparing patients on immunomodulators vs mesalamine or anti-TNF therapy, there was no difference in these outcomes. Conclusions The prevalence of COVID-19 in IBD patients was low. Use of corticosteroids or mesalamine was significantly associated with worse outcomes, whereas use of anti-TNFs was associated with more favorable outcomes. Further investigation clarifying the mechanisms of these disparate observations could help identify risk and adverse outcome-mitigating strategies for patients with IBD.

EPIDEMIOLOGICAL PROFILE AND CLINICAL CHARACTERISTICS OF INFLAMMATORY BOWEL DISEASES IN A BRAZILIAN REFERRAL CENTER

ABSTRACT BACKGROUND: The increase in the incidence and prevalence rates of inflammatory bowel disease (IBD) is evident in many newly industrialized countries in Asia, Africa, Eastern Europe, and the American continent. In Brazil, records are still scarce, and further studies on this topic are needed. OBJECTIVE: To evaluate the epidemiological profile and clinical characteristics of patients with IBD who were followed up at a reference service in the state of São Paulo. METHODS: We retrospectively analyzed the medical records of patients with IBD who were followed up in a Brazilian Referral Center. RESULTS: A total of 625 patients was evaluated, 416 with Crohn’s disease (CD), 190 with ulcerative colitis (UC), and 19 with indeterminate colitis. The average age of the patients was 31.6 years, with a homogeneous distribution between males and females patients. In patients with CD, the most predominant Montreal classification was A2, L3, and B1, with 44.8% of patients presenting with perianal disease; in UC, it was E2, and S0. The main extraintestinal manifestation was rheumatologic, followed by cutaneous and ophthalmic lesions. The majority of patients (85.4%) used some type of medication, the most frequent being aminosalicylates in patients with UC and biological therapy in patients with CD. Regarding surgeries, in CD, a significant percentage of patients underwent some type of surgical procedure, unlike the UC patients, including fistulotomies and placement of seton, derivative ostomies, enterectomy, ileocecectomy/right colectomy, total or partial colectomy, and strictureplasty. Only 195 (31.2%) patients lived in the city of Campinas, while 443 (70.9%) were from the 7th Regional Health Department (RHD), which corresponds to the macro-region of Campinas. CONCLUSION: In this study, most patients came from the 7th RHD of Campinas; the patients were young, with no predominance of either sex; there was a higher frequency of patients with CD (66.6%). Most of them (85.4%) were undergoing pharmacological treatment, and a significant percentage of CD patients had undergone surgery.

Difficulties of multidisciplinary diagnostics of indeterminate colitis

Aim of the study: Using the example of a clinical case, to show the importance of dynamic observation by means of various diagnostic methods of intestinal imaging, in combination with a pathomorphological confirmation method for setting the correct clinical diagnosis. Materials and methods: The studies were performed on multislice computed tomographs Brilliance CT and ICT (Philips Medical Systems) and magnetic resonance imaging machines (GE), with intravenous contrast enhancement. We used special methods of contrasting the lumen of the intestine with gradual and retrograde filling it with water. The surgical material fixed in 10% neutral formuline for 10-24 hours. Tissue fragments were processed in a Leica TP1020 histoprocessor (Leica BioSystems, Germany) according to a standard protocol, after which it was embedded in paraffin blocks. Histological sections with a thickness of 3-5 μm were made by a Leica RM2245 microtome (Leica BioSystems, Germany). The prepared histological preparations were stained with hematoxylin and eosin in a Leica Autosteiner XL histostiner (Leica BioSystems, Germany). Results: From 2013 to 2020 patient K. underwent 4 colonoscopies, 5 esophagogastroduodenoscopies, 1 Х-ray examination with small bowel series, 3 MRI studies and 5 CT studies, including those with intravenous contrast enhancement, with a total radiation exposure of 187 mSv. The diagnosis was revised from ulcerative colitis, Crohn’s disease to NC. The final diagnosis was made by the pathologist’s analysis of materials. Conclusion: The clinical case presented by us clearly demonstrates the importance of dynamic observation by computed and magnetic resonance imaging, in combination with a pathomorphological confirmation method.

P626 SARS-CoV-2 seroprevalence in patients with Inflammatory Bowel Disease

Background Patients with Inflammatory Bowel Disease (IBD) suffer from a chronic illness and many of them need immunosuppressive therapy throughout the course of the disease. Consequently, COVID-19 pandemic has caused uncertainty about the possible increased risk of suffering SARS-CoV-2 infection that could confer IBD or its treatments. The aim of this study is to assess SARS-CoV-2 seroprevalence in patients with IBD as well as the existence of potential risk factors for its development. Methods This is a unicentric cross-sectional study developed in IBD unit of University Hospital “Lozano Blesa” of Zaragoza. Patients older than 18 years with established diagnosis of Crohn′s Disease (CD), Ulcerative Colitis (UC) or Indeterminate Colitis (IC) have been included. A blood sample has been drawn from each patient to detect IgG against SARS-CoV-2 (ELISA method) and each patient has completed a questionnaire to know symptoms related to infection and previous comorbidity. We have performed a descriptive analysis and a univariate analysis to study relationship between potential risk factors and seroconversion against SARS-CoV-2. Results 431 patients have been included, with a mean age of 50.2 ± 14.1 years and a 51.3% of women. Of them, 49.7% suffer from UC, 49.2% CD and 1.2% IC. Related to the treatment, 23.5% receive anti-TNF biologic agents, 13.1% other kind of biologic agents, 9.3% immunomodulators, 7.7% combined treatment (biologic agent and immunomodulator), 33.1% other treatment and 13.3% no treatment. According to World Health Organization (WHO) definitions, 85.6% had not suffered the infection, 7.7% were confirmed cases (only 3 admitted patients) and 6.7% were probable cases. The seroprevalence of SARS-CoV-2 obtained is 8.8%, being significantly higher among confirmed cases than among probable cases (71.0% in confirmed vs 6.9% in probable; RR 10.3; p<0.001). A higher risk of seroconversion has been detected among patients without biologic agents (11.8% in patients without biologic agents vs 5.3% in patients with biologic agents; RR 2.2; p=0.021). No differences have been observed in the seroprevalence of patients with other treatments for IBD or in terms of age, active smoking, level of inflammation markers, the presence of symptoms of infection or hospital admission. Conclusion The seroprevalence of SARS-CoV-2 of Aragon′s patients with IBD is similar to that described in national seroprevalence study of Ministry of Health for the region (8.8%). The treatment with biologic agents is associated with a lower risk of seroconversion

P661 Radon exposure and inflammatory bowel disease in a radon prone area

Background Inflammatory Bowel Disease (IBD) is a multifactorial pathology with an increasing incidence. There are environmental factors, many unknown, that participate in its development. There is no study having assessed a possible relationship with residential radon exposure, which is very high in the study area. The aim of this study was to analyze if residential radon concentration measured at a municipal level is associated with a higher incidence of IBD and its characteristics (clinical or demographic). Methods We performed an ecological study where we included all incident cases of IBD in the area of Santiago de Compostela between January and December 2017 in order to estimate municipal incidence rates. Radon levels at a municipal level were obtained from the Galician Radon Map and correlated with demographic factors and type of IBD. We used the Spearman’s correlation coefficient to test the existence of any association. Results 96 patients were included, 63 (65.6%) with Ulcerative Colitis, 29 (30.25) with Crohn’s Disease and 4 (4.2%) with indeterminate colitis. Median age was 41 (IQR: 33.5 to 56 years), and 50.0% were women. The incidence rate per 100.000 inhabitants-year in the study area was 21.6 cases. The median radon concentration was 104.9Bq/m3 (IQR: 91.0 to 154.6), without statistically significant differences in function of the location of the house (rural vs. urban) nor the type of edification (flat vs house), p >0.05. There were no statistically significant differences on the type of IBD developed (ulcerative colitis, Crohn’s disease or indeterminate colitis) regarding radon levels either (p>0.05). There were no statistically significant differences (p>0.05) between radon and sex of IBD cases. No correlation between radon levels and age of the individuals was observed (Spearman’s rho = -0.13, p-value 0.2), nor radon levels variation by age groups (p>0.05). There was no correlation between radon concentration and cumulative incidence of IBD at municipal level (Spearman’s rho = 0.13, p-value 0.5), as it is shown in figure 1. Conclusion In the area of Santiago de Compostela there is a higher incidence of IBD in comparison with previous studies taking western countries as reference. It is possible that some environmental risk factors, could be responsible of this difference. In this study we have not found any correlation with municipal average radon concentration and incidence of IBD or any of its types.

P549 Changing Lanes: Switching Therapies in Inflammatory Bowel Disease, An Observational Study

Background Switching between therapies in inflammatory bowel disease (IBD) is common and a paucity of data exists regarding the optimal switching strategy. A number of new drug therapies have recently emerged for the treatment of IBD. Failure of biologic and small molecule therapies occur regularly, prompting the need for a treatment switch. Our aim is to review trends amongst our patients who switched biologic/small molecule therapy to identify high risk characteristics and to look for predictor variables which may reduce the need to switch in the future. Methods This is a 4 year retrospective observational study of IBD patients who underwent a therapy switch. Patients were identified from a prospectively maintained IBD database of 141 patients. Patient demographics, treatment history, disease history, biomarkers (within 3 months of switch) and endoscopy results were reviewed. Minitab17 was used for statistical analysis. Results Switching of biologic therapy was observed in 39 patients (28%); 21 (54%) were male; mean age was 42.8Y. Of these, 21 (53.9%) had Crohn’s disease (CD), 17 (44%) had ulcerative colitis (UC) and 1 patient had indeterminate colitis. Mean disease duration at time of switch was 78 months. 82% (n=14/17) of UC patients had pancolitis. 43% (n=9/21) of CD patients had a previous intestinal resection. The most common initial therapy was Adalimumab 46% (n=18) (Fig1) with the most common switch to IFX 36% (n=14) (Fig2). Primary LOR occurred in 28% (n=11) and secondary LOR in 44% (n=17), the remainder switched due to infusion reaction/adverse effects (n=10) and clinical remission (n=1). Mean CRP was 13.68 (95% CI: 7.28, 20.09), mean FCP was 874 (95% CI: 418, 1329), mean mayo score was 1.88 (95% CI: 1.37, 2.39), mean SES CD score was 5.79 (95% CI: 3.24, 8.33). Median IFX level was 0.8ug/ml (IQR 0.4, 9.7), 37.5% (n=6/16) of the patients on IFX developed ADAs to IFX. Median Adalimumab level was 5.2ug/ml (IQR 1.4, 13.5) and 11% (n=2/18) developed ADAs to Adalimumab. A significant negative correlation was found between FCP and IFX level using Spearman rank correlation -0.822, p = 0.01. 39% (n=15) were on an immunomodulator, no significant association was found between immunomodulator therapy and primary/secondary LOR, p= 0.67 and p= 0.63. 28% (n=11) were admitted with an IBD flare in the 1st year post switch and 13% (n=5) underwent intestinal resection. 8 (21%) subsequently switched to a 3rd biologic agent. Conclusion The most common therapy switch was within Anti-TNF drug class, mean CRP and FCP were raised at the time of switch and a significant number of patients were admitted in the year post switch with an IBD flare. Pancolitis in UC and previous intestinal surgery in CD were common characteristics of those who switched.