Are There Sufficient Data to Confirm a Protective Role for Anti-TNF in COVID-19?

A letter¹ to the editor published in Gastroenterology raised questions about research² reported in the same issue that described a protective role of anti-tumor necrosis factor (anti-TNF) against coronavirus 2019 (COVID-19) among patients with inflammatory bowel disease (IBD).

The published research article by Brenner and colleagues covered the Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD), an ongoing international registry survey that cataloged patients with IBD who had been infected with COVID-19. The article reported that among their patients, evidence of a protective role of anti-TNF therapy and a negative role for mesalamine, but not for corticosteroids, was observed.

Although the letter authors acknowledge that the SECURE-IBD study was still ongoing and the sample size has since increased by more than 1000 patients, they raised some concerns about the data. The reported patient population had a large proportion of patients on anti-TNF therapy (43.4%). Current clinical guidelines and factors about the participating treatment centers have led the authors to expect the proportion of patients on anti-TNF treatment to be closer to 30%.

The letter authors speculated that the enrichment of patients treated with anti-TNF therapy may be due to selection bias, as patients who are prescribed immunosuppressive drugs are closely monitored. The patients with IBD who were on a maintenance therapy of mesalamine and who had a mild case of COVID-19 or were asymptomatic may not have had the infection detected or diagnosed due to reduced contact with clinicians as compared with patients on immunosuppressive treatments. The authors asserted that due to the possible selection bias, further research should be conducted into the possible positive role of anti-TNF therapy and the negative role of mesalamine, and it remains unclear what role biologic treatment has in the cytokine storm phase of a COVID-19 infection.

The SECURE-IBD dataset had a low sample size of patients treated with steroids. Although evidence from previous outbreaks of coronavirus indicated that steroids should not be used due to detrimental outcomes, the lack of evidence for negative effects of corticosteroids indicated that further research into steroid use with COVID-19 is warranted.

The letter authors agree that the global pandemic should not be a reason to alter therapy for IBD; however, further investigation into COVID-19 infections among patients with IBD on various treatment regiments is needed.

Disclosure: Multiple authors declared affiliations with the pharmaceutical industry. Please refer to the original articles for a full list of disclosures.

References

1. Cappello M, Busacca A, Guida L. The course of Covid 19 in inflammatory bowel disease: protective role of TNF antagonists response to: corticosteroids, but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients with inflammatory bowel diseases: results from an International Registry. Gastroenterology. 2020;S0016-5085(20)34920-0. doi:10.1053/j.gastro.2020.06.087

2. Brenner E J, Ungaro R C, Gearry R B, et al. Corticosteroids, but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients with inflammatory bowel diseases: results from an international registry [published online July 8, 2020]. Gastroenterology. doi:10.1053/j.gastro.2020.05.032