Recent Data Bring COVID's Gastrointestinal Tolls Into Focus

David A. Johnson, MD


January 28, 2022

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

COVID-19 has been with us for 2 years now, with 300 million people infected and a resulting 3.5 million deaths worldwide at the time of this recording. In the United States, COVID-19 has infected 60 million citizens and caused 850,000 deaths. [Editor's note: As of the date of publication, COVID-19 has infected over 370 million people and caused 5.6 million deaths worldwide. In the United States, it has infected more than 74 million people and caused over 880,000 deaths.] These are undoubtedly catastrophic consequences.

During this time, we've also come to learn that COVID-19 infects — and has clear implications upon — the gastrointestinal (GI) tract.

With that in mind, I wanted to update you on some of the more recent studies in this area, which I think you'll find applicable to your clinical practice.

A Look at Some of the Latest Data

GI symptoms resulting from COVID-19 can persist from anywhere out to approximately 6 months or longer. Changes evident in the gut biome indicate that its effects are apparent well after the virus is cleared.

A recent study from China showed that there is diminished diversity in those who have had COVID-19, in the form of depleted short-chain fatty acids and L-isoleucine biosynthesis that promote gut integrity. This can go on for months after the clearance of the virus.

The implications for the GI tract after infectious enteritis include [intestinal disorders] like irritable bowel syndrome (IBS). Approximately 10% of patients with postinfectious enteritis develop IBS. Because the median duration of COVID-19 is 12 days, it is estimated that it may increase the likelihood of these postinfectious IBS-type symptoms by 10 times.

There are also now data suggesting that if patients have a preexisting mental health disparity, in particular anxiety or depression, they're twice as likely to develop more GI symptoms during the course of the virus and four times more likely after they've had the virus. This serves as a reminder to take a good mental health history, because it may prove meaningful to how you mitigate treatment.

COVID-19 also has a variety of implications relating to malnutrition. A retrospective analysis looked at 17,000 patients hospitalized with COVID-19 in a New York health system. It showed that malnutrition may be a very significant consequence of this disease and durable for up to 6 months. The median weight loss at 6 months in these patients was over 17 pounds. Over 50% of patients were unable to gain weight at 3 and 6 months. It's clear from these results that we need to focus on malnutrition and use that as a benchmark for assessing these patients during follow-up.

Varying Responses to Vaccination

There are also new data relating to vaccinations in patients with inflammatory bowel disease (IBD), particularly those who are on biologic therapies.

A provocative study led by investigators at Washington University in St. Louis looked at the protection against COVID variants, including Delta, after the second dose of the vaccine.

Three months after the second dose of the vaccine, only 8% of healthy volunteers fell below the proposed protective threshold of neutralizing antibodies for the Delta variant. However, 36% of immunocompromised patients with IBD and 67% of those on anti-tumor necrosis factor (TNF) inhibitors fell below this threshold.

More worrisome was the observation that, when assessing these patients out to 6 months beyond the second dose, only 17% of the healthy patients dropped below the estimated protection threshold, compared with 58% of the immunocompromised patients and 100% of those on TNF inhibitors.

Once again, the reminder here is to vaccinate, vaccinate, vaccinate. These patients must get their booster shots, in particular prioritized for those at risk of reduced protection. You really need to push them on this.

It's estimated that [approximately 4%] of patients can't take the COVID vaccines or booster shot because they have some type of intolerance or allergy or an immunologic nonresponse. There's good news for these patients too, with the recent authorization by the US Food and Drug Administration of a long-acting monoclonal antibody cocktail: tixagevimab co-packaged with cilgavimab and administered together. This is a one-shot booster that lasts for up to 6 months and may be a viable option for your patients going forward.

Hopefully, some of these new GI-related COVID-19 data updates will have a meaningful impact on your discussions with your patients.

I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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