Many IBD Patients Skipped or Reduced Medication Doses Because of the COVID-19 Pandemic

One in 20 patients with inflammatory bowel disease (IBD) skipped or reduced doses of their medications or stopped taking prescribed drugs altogether during theCOVID-19 pandemic, according to astudy published in March 2021 in theJournal of Gastroenterology and Hepatology Open.

The study, based on a survey of 262 IBD patients in Australia, didn’t examine why some people cut back on prescribed medications. But it’s possible that stay-at-home orders and rising unemployment during the pandemic played a role, along with mistaken concerns that IBD medications could increase the risk of getting COVID-19 or having severe illness, says the lead study author,Alex Barnes, MD, MPH, a gastroenterologist at the College of Medicine and Public Health at Flinders University in Adelaide, South Australia.

“I would hope that efforts to spread information regarding the safety of IBD medications in the setting of the COVID-19 pandemic would have been successful in convincing a significant proportion of people to be adherent to IBD medications during the pandemic,” Dr. Barnes says.

One troubling finding in the study is that most patients who cut back on their medications didn’t discuss it with the specialist treating them for IBD, particularly because reducing or stopping treatment was associated with several negative health consequences. In particular, patients who reduced or stopped medication usage had increased disease activity, lower rates of remission, and a greater reliance onprednisoneand othercorticosteroidsto keep symptoms in check.

“Medication nonadherence could result in a flare and the need forprednisolone— a medication associated with worse COVID-19 outcomes,” Barnes says. “The take-home message would be to continue on maintenance IBD medication in order to reduce the use of prednisolone and the consequent risk of worse COVID-19 outcomes.”

Healthcare Utilization Decreased Early in the Pandemic

The study was small, and it wasn’t representative of all patients in Australia with IBD. Because participants were recruited from IBD treatment centers, it’s also possible that patients in the study were more engaged with their own care and more apt to take medications as directed than a typical individual with IBD, the study team notes.

The survey also wasn’t designed to determine whether any changes in IBD medication regimens during the pandemic directly impacted COVID-19 risk or whether these changes might have a long-term impact on the course of IBD. It was also conducted before vaccines were widely available for COVID-19, which might influence patients’ decisions about IBD medication.

Early in the pandemic, healthcare utilization dropped across the board, not just for patients with IBD, saysBerkeley Limketkai, MD, PhD临床研究中心主任for inflammatory bowel diseases at the David Geffen School of Medicine at the University of California in Los Angeles.

“There was an overall fear of seeking medical attention in person, obtaining tests or procedures which would have led to recommendations for medical treatment, going to the pharmacy, and other activities that would require in-person interactions,” says Dr. Limketkai, who wasn’t involved in the study.

“Fortunately, with the availability of the vaccine, known safe practices, and more controlled prevalence of COVID, at least in the United States, patients should now feel relatively okay to pursue their standard medical care and take their prescribed IBD medications,” Limketkai adds.

The Relationship Between IBD Medications and Risk of COVID Infection

Results from the current study mirror medication nonadherence findings from a study of U.S. veterans with IBDpublished in June 2020 inGastroenterology. This examined prescription data for more than 2,500 patients in 2019, before the pandemic, and for 2,500 patients in 2020, during the pandemic. Researchers found that nonadherence to IBD medications increased by 70 percent during the pandemic.

Like the current study, this earlier study of U.S. veterans found that patients who didn’t take IBD medicines as prescribed were significantly more likely to require treatment with corticosteroids like prednisone.

Anotherstudy inGastroenterology, published in May 2020, examined data on 525 patients with IBD who were diagnosed with COVID-19. This study found that people who took corticosteroids were almost seven times more likely to develop severe COVID-19. But injected medicines known as tumor necrosis factor (TNF) antagonists, commonly prescribed for IBD, didn’t appear to influence the risk of severe COVID-19.

Early in the pandemic, many patients may have been concerned that TNF antagonists might weaken the body’s immune response to COVID-10, Limketkai says. That’s because these drugs work by suppressing the immune system and blocking the activity of TNF, a substance that can cause inflammation and exacerbate symptoms of IBD.

“The level of fear or anxiety surrounding the discussion of immunosuppressive medications is very different now,” Limketkai says. “Part of this attenuation of fear and anxiety relates to research data that have shown the use of nonsteroid medications to be not as detrimental or fatal as originally feared.”

Other Reasons to Stick With IBD Treatment

The goal of IBD medication is to maintain remission and avoid symptom flares that can lead to a significantly worse quality of life and also result in the need for corticosteroids, hospitalizations, and surgery, saysBharati Kochar, MD, of the Crohn’s andcolitiscenter at Massachusetts General Hospital in Boston.

In the case of immunosuppressive therapies like TNF antagonists, skipping doses or erratic dosing schedules can also increase the risk of developing antibodies to the medicine, says Dr. Kochar, who wasn’t involved in the current study.

“Over time, this may result in the need to stop that therapy and switch to another one, which may not be as effective,” Kochar says. Patients who experienced remission before may struggle to achieve this again, Kochar adds.

Too many patients, however, perceive their medications as being riskier than the consequences of stopping treatment, Kochar says.

“The majority of medications prescribed to treat IBD are forms of immunosuppression, which is often perceived as ‘dangerous’ and therefore scary to take if you’re not educated on whether the solution is worse than the problem,” Kochar says.

While it’s completely reasonable for patients to be worried about how their IBD diagnosis and the medications they take might impact their risk for COVID-19, stopping treatment without talking to a doctor can be dangerous, Kochar cautions.

“The bottom line for patients should be to talk to your doctor before making any changes to your medication regimen or if you have concerns about staying on your medications,” Kochar says.