Treatment of severe acute ulcerative colitis in SARS-CoV-2 infected patients: report of three cases and discussion of treatment options

Abstract

In the wake of the coronavirus disease 2019 (COVID-19) pandemic, it is unclear how asymptomatic severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-infected patients who present with acute severe ulcerative colitis (UC) can be treated effectively and safely. Standard treatment regimens consist of steroids, immunomodulatory drugs, and biological therapies, but therapeutic decision-making becomes challenging as there are uncertainties about how to deal with these drugs in patients with COVID-19 and active UC. Importantly, guidelines for this particular group of patients with UC are still lacking. To inform therapeutic decision-making, we describe three consecutive cases of patients with active UC and COVID-19 and discuss their treatments based on theoretical knowledge, currently available evidence and clinical observations. Three patients were identified through our national inflammatory bowel disease network [Initiative on Crohn’s and Colitis (ICC)] for whom diagnosis of SARS-CoV-2-infection was established by reverse transcription–polymerase chain reaction (RT-PCR) testing in nasopharynx, stools, and/or biopsies. Acute severe UC was diagnosed by clinical parameters, endoscopy, and histopathology. Clinical guidelines for SARS-CoV-2-negative patients advocate the use of steroids, calcineurin inhibitors, or tumor necrosis factor alpha (TNF-α)-antagonists as induction therapy, and experiences from the current three cases show that steroids and TNF-α-antagonists could also be used in patients with COVID-19. This could potentially be followed by TNF-α-antagonists, vedolizumab, or ustekinumab as maintenance therapy in these patients. Future research is warranted to investigate if, and which, immunomodulatory drugs should be used for COVID-19 patients that present with active UC. To answer this question, it is of utmost importance that future cases of patients with UC and COVID-19 are documented carefully in international registries, such as the SECURE-IBD registry.

Use of Tumor Necrosis Factor-α Antagonists Is Associated With Attenuated IgG Antibody Response Against SARS-CoV-2 in Vaccinated Patients With Inflammatory Bowel Disease

“…Likewise, a previous study conducted in solid organ transplant recipients showed reduced antibody formation in patients who were using antimetabolite agents including azathioprine and mycophenolate mofetil ( 26 ). However, another study did not demonstrate reduced antibody formation against SARS-CoV-2 for any type of IBD medication except the use of systemic steroids, for which we only observed reduced antibody concentrations in univariate analysis ( 9 ). Additionally, the recent VIP-study identified tofacitinib as an immunosuppressant with a substantial immunogenicity-attenuating effect ( 27 ).…”

“…Reassuringly, current data do not indicate the existence of an increased susceptibility to contract SARS-CoV-2 in patients with IBD receiving immunosuppressive treatment, nor do patients with IBD experience a more severe disease course after SARS-CoV-2 infection (8,9). However, early findings suggest that certain immunosuppressive agents, especially TNFa-antagonists, may have attenuating effects on the serological response after SARS-CoV-2 infection (10,11).…”

The Disease-Modifying Role of Taurine and Its Therapeutic Potential in Coronavirus Disease 2019 (COVID-19)

“…ACE2 was also found to be expressed on the enterocytes of the small intestine, as well as the vascular endothelium and arterial smooth muscle cells in various organs, supporting potential oral and blood-borne infectious routes, respectively (Hamming et al 2004). In line with this wide tissue distribution of ACE2, the presence of SARS-CoV-2 has been demonstrated in various organs other than the lungs (Bourgonje et al 2021b;Schurink et al 2020;Song et al 2021). For example, a cohort autopsy study examined the systemic SARS-CoV-2 distribution in postmortem organs from 26 COVID-19 patients and found SARS-CoV-2 in, among others, the lungs (92%), hilar lymph nodes (76%), small intestine (31%), colon (23%), heart (19%), and kidneys (15%) (Yao et al 2021).…”

Managing IBD in the COVID-19 era

“…68 Vigano et al emphasized that current data supports that biologics remain the first-line treatment for induction and maintenance of remission in cases of ASUC and concurrent COVID-19. 80 Bourgonje et al 81 (2021) recently described the importance of not delaying therapy in a three consecutive case series of patients with ASUC and COVID-19, in which postponement of intravenous steroids led to a poor surgical outcome. The increased surgical risk of COVID-19 infection must be considered against the risk of delaying intervention in ASUC.…”