Edward Loftus, MD, on Infectious Complications in IBD

Dr Loftus reviews his presentation at AIBD 2020 Virtual on how to manage infections in patients with inflammatory bowel diseases.

Edward Loftus, MD, is a professor of medicine at the Mayo Clinic in Rochester, Minnesota.

TRANSCRIPT

Hi, I'm Ed Loftus. I'm a Professor of Medicine at Mayo Clinic in Rochester, Minnesota, and I gave at talk at Advances in Inflammatory Bowel Disease on infectious complications in IBD and how to manage infections in an IBD patient.

Part of the challenge with this type of talk is that most of the data is based on retrospective observational studies. There's a lot of confounders. Part of deciphering these studies is teasing out how much of the infection risk is related to the underlying disease, how much is related to other medications that the patient would be on, or how much is related to a particular medication, or is not medication-related at all.

I talk a little bit about the risk factors for infections in IBD, including older age, a new concept of frailty as a predictor of infection. Frailty isn't just age. It's looking at codes for things like falling, malnutrition, or difficulty walking.

It turns out that frailty is actually a bigger predictor of morbidity and things like infections in IBD patients than just a chronological age. That makes sense, because many of us have seen people that, "Oh, they're a good 70," or, "They're a not-so-good 70." Frailty is probably better than age.

Then I talked about malnutrition, and then the various medications. Just to give an overview of that, there are conflicting data as to which medication class seems to cause the most amount of serious or opportunistic infections.

Perhaps the best study on this came from France, a big French national database, where they examined the risk of both serious and opportunistic infections. Remember, those are two different things. Serious infections are infection that are severe enough to land you in the hospital.

Opportunistic infections are infections with pathogens that, in a normal host, don't cause infection. Not all serious infections are opportunistic, and not all opportunistic infections are serious. The reason I make that distinction is there actually is a little bit of a difference between the two classes, immunomodulators versus anti-TNF, with respect to those issues.

In that French study, serious infections were more common in anti-TNF-treated patients, at least twice as more common. Whereas opportunistic infections were about the same risk in either class of medication. Then, of course, combination therapy produced the highest risk of infections.

Then I talked a little bit about steroids. Steroids are still the worst of all the drug classes in terms of infection risk. That's been shown in multiple different studies, and we'll talk about a couple of those. Then we talk about vedolizumab and its risk of infection relative to other infections.

Again, there's conflicting data on that. We have some comparative efficacy studies, observational studies from the Victory Consortium, that suggest that there isn't too much of a difference, although it might depend on whether or not you're biologic-naÔve or biologic-exposed.

The people that are biologic-exposed actually seem to have a higher risk of infection with vedolizumab than if they had been bio-naÔve. Maybe that makes sense. That's a reflection of bowel damage.

Then, using that same French national database that I just talked about and two US commercial claims databases, there was a study presented at UEGW just a couple of months ago comparing risks of infection with vedolizumab versus anti-TNFs.

Again, a similar theme, that you couldn't always demonstrate a difference. In UC, there was a lower risk of infections with vedolizumab, but in Crohn's disease, it was about the same, so food for thought there.

Then I talked about specific different types of infections, including the risk of zoster, the risk of CMV colitis. Don't forget about CMV colitis in that steroid-refractory patient, especially if they were already immunosuppressed, because if they high density of viral inclusions, antiviral therapy may be helpful.

There were certain areas I really just glanced over, because they're going to be covered in other sections of advances. The C. diff infection, yes, it's increased in IBD patients. IBD itself is a risk factor for C. diff, and we have vancomycin, fidaxomicin, but we also have fecal microbial transplantation in patients who recur.

Again, there's going to be a whole session on C. diff at the meeting. I did not talk about COVID, which is a very relevant infection, because again, there's a whole section on COVID and the various medications. I did not get into that.

Talked a little bit about zoster, that some of the drugs that cause immunosuppression increase the risk of that. In tofacitinib in particular, that can be mitigated by use of the relatively new recombinant vaccine. Then talked about a few other unusual infections, like histoplasmosis and pneumocystis.

This is a recognized issue. It can be managed. I think, in general, your principles should be, in an active infection, is I would tend towards continuing the biologic, or if holding, holding just briefly. You could probably discontinue the immunomodulator temporarily and then, again, try to rapidly wean corticosteroids. I thank you for your attention. Thanks.