Risk and outcomes of coronavirus disease in patients with inflammatory bowel disease: A systematic review and meta-analysis

Abstract

Background: The risk of severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) infection and clinical outcomes of coronavirus disease (COVID-19) in inflammatory bowel disease are unclear.

Methods: We searched PubMed and Embase with the keywords: inflammatory bowel disease, Crohn's disease, ulcerative colitis and COVID-19, novel coronavirus and SARS-CoV-2. We included studies reporting the frequency of COVID-19 infection and outcomes (hospitalisation, need for intensive care unit care and mortality) in patients with inflammatory bowel disease. We estimated the pooled incidence of COVID-19 in inflammatory bowel disease and comparative risk vis-a-vis the general population. We also estimated the pooled frequency of outcomes and compared them in patients who received and did not receive drugs for inflammatory bowel disease.

Results: Twenty-four studies were included. The pooled incidence rate of COVID-19 per 1000 patients of inflammatory bowel disease and the general population were 4.02 (95% confidence interval [CI, 1.44-11.17]) and 6.59 [3.25-13.35], respectively, with no increase in relative risk (0.47, 0.18-1.26) in inflammatory bowel disease. The relative risk of the acquisition of COVID-19 was not different between ulcerative colitis and Crohn's disease (1.03, 0.62-1.71). The pooled proportion of COVID-19-positive inflammatory bowel disease patients requiring hospitalisation and intensive care unit care was 27.29% and 5.33% while pooled mortality was 4.27%. The risk of adverse outcomes was higher in ulcerative colitis compared to Crohn's disease. The relative risks of hospitalisation, intensive care unit admission and mortality were lower for patients on biological agents (0.34, 0.19-0.61; 0.49, 0.33-0.72 and 0.22, 0.13-0.38, respectively) but higher with steroids (1.99, 1.64-2.40; 3.41, 2.28-5.11 and 2.70, 1.61-4.55) or 5-aminosalicylate (1.59, 1.39-1.82; 2.38, 1.26-4.48 and 2.62, 1.67-4.11) use.

Conclusion: SARS-CoV-2 infection risk in patients with inflammatory bowel disease is comparable to the general population. Outcomes of COVID-19-positive inflammatory bowel disease patients are worse in ulcerative colitis, those on steroids or 5-aminosalicylates but outcomes are better with biological agents.

Keywords: Crohn's disease; SARS-CoV-2; coronavirus; ulcerative colitis.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow chart showing selection process of the studies

FIGURE 2

Pooled incidence of COVID in IBD and the general population and relative risk of COVID infection in IBD patients as compared to the general population. The pooled summary was computed by a random effect approach. CI, confidence interval; COVID, coronavirus disease; IBD, inflammatory bowel disease

FIGURE 3

Pooled risk ratio of COVID infection in IBD patients depending on use of various drugs (5‐ASA, steroids, immunomodulators, biological agents, anti‐TNF, vedolizumab and ustekinumab). The pooled summary was computed by a random effect approach. 5‐ASA, aminosalicylic acid; CI, confidence interval; COVID, coronavirus disease; IBD, inflammatory bowel disease; TNF, tumour necrosis factor

FIGURE 3

Pooled risk ratio of COVID infection in IBD patients depending on use of various drugs (5‐ASA, steroids, immunomodulators, biological agents, anti‐TNF, vedolizumab and ustekinumab). The pooled summary was computed by a random effect approach. 5‐ASA, aminosalicylic acid; CI, confidence interval; COVID, coronavirus disease; IBD, inflammatory bowel disease; TNF, tumour necrosis factor

FIGURE 4

The pooled prevalence of various outcomes (hospitalisation, need for ICU and mortality) in IBD patients with COVID. The pooled summary was computed by a random effect approach. CI, confidence interval; COVID, coronavirus disease; IBD, inflammatory bowel disease; ICU, intensive care unit

FIGURE 5

The pooled relative risk of various outcomes (hospitalisation, need for ICU and mortality) in UC versus CD. The pooled summary was computed by a random effect approach. CD, Crohn's disease; CI, confidence interval; ICU, intensive care unit; UC, ulcerative colitis

FIGURE 6

The pooled relative risk of various outcomes (hospitalisation, need for ICU and mortality) in IBD COVID patients with respect to the use of various drugs (5‐ASA, steroids, immunomodulators, biological agents, anti‐TNF, vedolizumab and ustekinumab). The pooled summary was computed by a random effect approach. 5‐ASA, aminosalicylic acid; CI, confidence interval; IBD, inflammatory bowel disease; ICU, intensive care unit; TNF, tumour necrosis factor

FIGURE 6

The pooled relative risk of various outcomes (hospitalisation, need for ICU and mortality) in IBD COVID patients with respect to the use of various drugs (5‐ASA, steroids, immunomodulators, biological agents, anti‐TNF, vedolizumab and ustekinumab). The pooled summary was computed by a random effect approach. 5‐ASA, aminosalicylic acid; CI, confidence interval; IBD, inflammatory bowel disease; ICU, intensive care unit; TNF, tumour necrosis factor

FIGURE 6

The pooled relative risk of various outcomes (hospitalisation, need for ICU and mortality) in IBD COVID patients with respect to the use of various drugs (5‐ASA, steroids, immunomodulators, biological agents, anti‐TNF, vedolizumab and ustekinumab). The pooled summary was computed by a random effect approach. 5‐ASA, aminosalicylic acid; CI, confidence interval; IBD, inflammatory bowel disease; ICU, intensive care unit; TNF, tumour necrosis factor