IBD and Coronavirus (COVID-19): Risks, Complications

Inflammatory bowel diseases (IBD), which include Crohn’s disease, ulcerative colitis, and indeterminate colitis, are incurable conditions of the digestive tract. From the start of the coronavirus pandemic, people who live with an IBD have been concerned about how they would fare upon developing COVID-19.

There doesn’t appear to be a link between having IBD and being more susceptible to becoming infected with the coronavirus. For the most part, there also does not appear to be a link between IBD and having a worse course of COVID-19.

IBD and COVID-19 Risk

There are two considerations with COVID-19 and IBD: if patients with IBD are at increased risk for being infected, and if the course of the infection would be worse than it is for those who don’t live with an IBD.

It’s already known that older people and those with certain health conditions (including diabetes, obesity, and chronic lung disorders) may be at a higher risk of having a severe course of COVID-19. This could include the need for treatment in a hospital.

However, there’s currently no evidence that people who live with an IBD would fare worse with COVID-19. The Centers for Disease Control and Prevention (CDC) has not added IBD to their list of conditions that are associated with a worse course of COVID-19.

People with IBD appear to get infected with COVID-19 at the same rates as the general population. In other words, having Crohn’s disease or ulcerative colitis doesn’t make a person any more or less likely to catch the virus.

One study found that people with IBD had a milder course of COVID-19. That might be because doctors have stressed caution and patients have taken that advice to heart in order to avoid becoming infected with the coronavirus. Another study showed that it was rare for people with IBD to have a severe outcome with COVID-19.

Complications of IBD and COVID-19

A study in the Netherlands looked at the outcomes of COVID-19 infection in people with IBD. Similar to other studies, the researchers found that people with IBD were not at increased risk of being infected with the coronavirus.

In the patients with IBD who had COVID-19, the most common symptoms were cough (80%), fatigue (79%), shortness of breath (73%), fever (61%), muscle aches and pains (myalgia) (41%), nausea (27%), and vomiting (9%). In particular, fatigue, fever, myalgia, nausea, and vomiting may also occur with an IBD flare-up.

Patients with IBD who are at the highest risk of developing complications after having COVID-19 are roughly the same as in the general population. That includes those patients who are older and who live with another health problem, especially the conditions already known to increase the risk of poor outcomes with COVID-19.

Another factor is the IBD itself. Having poor disease control may be related to worse outcomes, as one study pointed out. There may or may not be a link between corticosteroids and more severe COVID-19, but it’s not known if this is because patients prescribed steroids may also have more severe IBD.

A COVID-19 infection can cause digestive symptoms. For people who live with an IBD, it will be important to tell the difference between IBD symptoms and COVID-19 symptoms.

Not an easy task, but in general, the symptoms that came on after infection should be gone when the virus has cleared from the body. If symptoms of diarrhea, nausea, vomiting, fever, and joint pain continue after recovering from COVID-19, it will be important to check in with a gastroenterologist.

People who have lingering effects of COVID-19 after clearing the virus from their system are often referred to as “long haulers.” There’s currently no evidence showing that people with IBD are either more or less likely to have long-term complications after having COVID-19.

Some of the studies looking at how people with IBD have fared after having COVID-19 even cautiously speculate that people with IBD might be at a lowered risk of COVID-19 infection. The evidence is weak, but it’s a possibility.

One reason given is that people with IBD may have less of a certain cell type in the digestive tract (angiotensin-converting enzyme 2, or ACE2) that uptakes viruses.

A second reason could be that some medications (namely certain immunosuppressive drugs and biologics) used to treat IBD may prevent a cytokine storm. The cytokine storm is the uncontrolled immune system reaction that is thought to be part of the severe outcomes in people who have COVID-19.

IBD Treatments and COVID-19

Researchers have collected information from patients with IBD in several countries who developed COVID-19. They looked at many different factors of IBD, including which form of the disease patients had, how active it was at the time of infection, and what medications were being given.

That’s allowed scientists to make some conclusions about how different drugs used for IBD may affect COVID-19.

The SECURE-IBD registry collected data about people with IBD from all over the world who developed COVID-19. After 1,400 patients were in the registry, the results from the data about different IBD medications were published.

While some conclusions were made, there were also limitations with the data and there’s still not a full understanding of some of the results.

For instance, the patients in the registry may have been sicker, may have received more care than the average IBD patient, and there were more White patients included than those of other races and ethnicities.

Thiopurines

The medications that suppress the immune system called thiopurines, azathioprine and 6-mercaptopurine, are used to treat IBD. Sometimes they are used by themselves (monotherapy) and sometimes they are used at the same time as another drug (combination therapy).

The registry study found that people who took a thiopurine, either by itself or along with an anti-tumor necrosis factor (TNF) medication (such as Remicade or Humira), had higher rates of certain complications. This was in comparison to people with IBD who took only an anti-TNF medication, not the general population.

The authors of the study recommend that doctors who treat IBD patients consider thiopurines carefully in individual patients. In some cases, there may be a reason to stop a thiopurine in patients who are at high risk for COVID-19 complications for other reasons (such as age or another health problem).

Mesalamine and Sulfasalazine

The same researchers found that IBD patients who were taking 5-aminosalicylic acid medications such as Asacol (mesalamine) or Azulfidine (sulfasalazine) may also have a higher risk of severe COVID-19.

This was in comparison to patients who were not taking these medications. Normally these drugs do not have a connection to an increased risk of infections because they do not act on the immune system. 

This is the first study to make a link, so the authors are not able to draw any real conclusions. One potential reason is that it only seems like there’s an increased risk because it’s being compared against medications that are associated with a decreased risk.

Another reason could be that patients taking these medications are being undertreated in the first place and may have more severe IBD. A third point is that because biologics are so expensive and these medications are cheaper, they might be used more frequently in people who have less access to care for their IBD.

The authors don’t recommend changing medications for patients taking mesalamine or sulfasalazine based on the result of this research.

TNF Agonists

The outcome of the registry study suggests that the TNF-agonist medications (such as Remicade, Humira, Cimzia, Simponi, and their biosimilars) may protect against severe COVID-19. This is when compared to other IBD medications, such as thiopurines or the 5-aminosalicylic acid (ASA) drugs.

Other research has shown that high levels of TNF may be associated with an increased risk of death from COVID-19. It makes sense, then, that medications that dampen TNF levels might be protective.

IL-12/23 Antagonist Therapy

Stelara (ustekinumab) is another type of biologic that works by suppressing IL (interleukin) -12 and -23, which are known to be important in causing IBD inflammation.

The authors of the registry study note that there also seemed to be a protective effect with this medication against the risk of severe COVID-19. The effect is considered to be similar to the TNF agonists.

Corticosteroids

It’s now understood that reducing the use of steroids (such as prednisone) for treating IBD is important for reducing the risk of adverse effects. However, steroids are often used as a rescue medication for flare-ups and in countries where newer medications like biologics are not available.

The use of steroids to treat COVID-19 is also well known, but there are key differences in how they’re used for IBD vs. how they’re being used to treat those with severe COVID-19 infections.

For patients with IBD who are taking steroids, th registry study also found an increased risk of more severe COVID-19. It’s thought that taking steroids when first infected may prevent the immune system from mounting a robust response to the virus.

When COVID-19 becomes severe, some patients are treated with a type of steroid (dexamethasone) which may help modulate the cytokine storm. In addition, it could be that patients taking steroids have uncontrolled IBD and that is also a risk for having a more serious course of COVID-19.

How medications may or may not have an effect on COVID-19 is individual to each patient. How their disease is behaving, the community risk of COVID-19, and factors like age and other health problems are important considerations.

Most cases of severe COVID-19 in IBD patients were in those who were over the age of 50 years. People with IBD should not change their medications or how they take their medications because of the pandemic.

Keeping the IBD under control is important to preventing severe COVID-19, so sticking to a plan that’s working and in remission is the best idea. Medication changes should only be made after careful discussion with a gastroenterologist.

Frequently Asked Questions

Should I get a COVID-19 vaccine if I have Crohn’s disease or ulcerative colitis?

The CDC recommends that people get vaccinated against COVID-19 as soon as they are eligible. The gastroenterology community also recommends that people who live with an IBD get vaccinated.

Checking with your own healthcare professional is important, but broadly speaking, the vaccines are considered safe. Based on data from studies of other types of vaccines, they are expected to be effective in people who live with an IBD.

Vaccination is recommended for all patients with IBD, no matter what other health problems are present or what drugs they are taking.

Which vaccine should people with IBD receive?

The prevailing opinion stressed by public health and government officials is that people receive the first vaccination available to them. It’s not recommended to wait to get vaccinated to get one brand of vaccine over another. What is important is for those vaccines where a second dose is needed, that second dose is given on time. 

Are the COVID-19 vaccines safe for people receiving biologics or immune-suppressive medications?

The only vaccines that are not recommended for people taking a biologic or a drug that suppresses the immune system are those that contain a live virus. None of the COVID-19 vaccines being given in the United States contain a live virus.

Will a COVID-19 vaccine cause IBD to flare up?

There is still more data to gather on the experiences of IBD patients with the COVID-19 vaccine. However, based on other studies of IBD patients receiving various types of vaccines (such as the H1N1 flu vaccine), there’s no evidence that vaccines cause IBD flare-ups.

Vaccines do cause an immune response, but this is not shown to affect IBD. The immune system is complicated; it is not as simple as turning it “on” or “off.” Vaccines cause narrow responses that create specific antibodies to a virus, which helps protect the body from infection. 

Do IBD patients have more side effects after receiving a COVID-19 vaccine?

Side effects are not uncommon after receiving a COVID-19 vaccine. They are typically self-limiting, meaning that they resolve on their own.

One pre-print study of more than 200 people with IBD showed that 39% had a side effect after the first dose of a COVID-19 vaccine and 62% had a side effect after the second dose. After the first dose/second dose, this included fatigue/malaise (23%/45%), headache/dizziness (14%/34%), and fever/chills (5%/29%).

There were only about 2% of patients that reported their effects to be “severe.” Digestive symptoms were also reported after the first and second doses at 6% and 12%, respectively.

The risk of side effects in people with IBD is similar to the general population. However, the authors note that their study did not include enough patients from a spectrum of racial and ethnic groups.

How to Stay Safe

It’s recommended that people who live with an IBD stay in close contact with their physicians and keep taking their medication during the public health emergency. People with IBD should continue to avoid the risk of infection by following the general guidelines for COVID-19:

• Avoid close contact with people outside one’s household.
• Avoid being within 6 feet of anyone who has a respiratory infection, fever, or cough.
• Use alcohol-based hand sanitizer when soap and water is not available.
• Wash hands frequently.
• Wear a mask that covers the mouth and the nose.

A Word From Verywell

At the start of the pandemic, people with IBD did not have much guidance to understand if there was a greater risk of COVID-19 or not. It’s now understood that people with IBD are not at higher risk for infection or severe disease from COVID-19 than the general population.

This is good news and reassuring, although people with IBD will want to continue to avoid infection if possible. The vaccines were another open question, and the first data coming out shows that they are safe and effective in people who live with an IBD.

There is still more information needed about those who take immune-modifying medications and if vaccination can be less effective. However, getting vaccinated is still recommended because some immunity is better than none. Always ask a physician any questions related to IBD or to change a care plan.

The information in this article is current as of the date listed. As new research becomes available, we’ll update this article. For the latest on COVID-19, visit our coronavirus news page.