Letter: SARS‐CoV‐2 infection in two IBD patients treated with dual targeted therapy

Short abstract

LINKED CONTENT

This article is linked to Al‐Ani et al papers. To view these articles, visit https://doi.org/10.1111/apt.15779 and https://doi.org/10.1111/apt.16297

EDITORS,

We read with interest the review by Al‐Ani addressing the management of IBD patients during the current COVID‐19 pandemic. ¹ Since its beginning, the wide spread SARS‐CoV‐2 infection has represented a major concern for IBD patients and their physicians, due to the unknown implications of immunomodulatory therapies on the course of the infection. However, earliest experiences from the SECURE‐IBD registry already suggested that comorbidities, increasing age and chronic corticosteroid use—but not anti‐TNF treatment—were the main factors associated with unfavourable outcomes. ² Furthermore, a prospective Italian study showed that active IBD was associated with worse outcomes in patients with SARS‐CoV‐2 infection. ³ In the last work from the SECURE‐IBD registry, Ungaro and colleagues showed that chronic corticosteroids, mesalazine (mesalamine) and thiopurines—but not biologics of any class—correlated with an increased risk of severe COVID‐19. ⁴ Comprehensively, these lines of evidence support the idea that, in this era of SARS‐CoV‐2 pandemic, IBD control should probably be prioritised over theoretical risks of more severe COVID‐19 and complications associated with biologics.

In the last few years, dual targeted therapy (DTT) has been selectively used in complex IBD patients. ⁵ Whether DTT might be associated with an increased risk of SARS‐CoV‐2 infection or more severe COVID‐19 manifestations, compared to biologic monotherapy, is unknown. In our clinic, 11 patients are currently receiving DTT. Here, we report two patients with Crohn's disease (CD) treated with DTT who tested positive for SARS‐CoV‐2. Both discontinued biologic therapy while positive and resumed it after seroconversion. The first patient is a 49‐year‐old woman treated with adalimumab (last administration November 11th) and vedolizumab (last infusion November 3rd). She tested positive for SARS‐CoV‐2 on November 12th. She developed fever (maximum temperature 38°C), arthralgias and mild respiratory insufficiency requiring transient domiciliary oxygen therapy. Her symptoms resolved after 9 days; she tested negative at the second swab, on December 3rd (duration of positivity: 21 days). The second patient is a 36‐year‐old woman receiving adalimumab (last administration November 5th) and vedolizumab (last administration November 11th). She tested positive for SARS‐CoV‐2 on November 13th. She was asymptomatic at the time and developed no respiratory symptoms afterwards; however, after 2 weeks, she had diarrhoea, possibly related to active IBD or gastrointestinal manifestations of COVID‐19. She finally tested negative, at her second swab, on December 7th (duration of positivity: 25 days).

Both patients had viral positivity duration longer than 20 days, compared to the median reported in the general population (12 days). ⁶ , ⁷ One patient developed respiratory symptoms, while the other only had gastrointestinal symptoms. Neither required hospitalisation and did not have severe complications of COVID‐19. Based on these data, we cannot exclude that DTT might increase the risk of contracting the infection or prolong the duration of viral positivity by reducing virus clearance. However, the overall mild course of disease is reassuring and does not suggest that combination of biologics is associated with worse outcomes in IBD patients.