University of Chicago Medicine section chief of Gastroenterology, Hepatology and Nutrition, David T. Rubin, MD, answers common questions about coronavirus (COVID-19) and inflammatory bowel disease, which includes Crohn’s disease and ulcerative colitis.
What are the symptoms of COVID-19 and are they different for inflammatory bowel disease patients?
Patients who are infected with the novel coronavirus called SARS-CoV-2 may develop a disease called COVID-19. The symptoms of COVID-19 are most frequently fever, cough and other respiratory symptoms, which might progress to shortness of breath. Other common symptoms include fatigue or muscle aches. Some digestive symptoms have been associated with COVID-19 as well, including a loss of appetite, a loss of smell or taste, abdominal discomfort, more frequent bowel movements or loose stools.
We haven’t seen enough IBD patients who’ve developed COVID-19 to know whether these patients have different types of symptoms but for patients with IBD, having digestive symptoms could be confused for activation of IBD. The unique concern here is to distinguish between someone who is having a relapse of their IBD, compared to someone who might be having symptoms of an infection. We’re working hard with our patients and performing additional research to figure this out.
Are inflammatory bowel disease patients considered immunosuppressed? Do they have a higher risk of contracting COVID-19?
Patients who have Crohn’s disease and ulcerative colitis have a chronic condition in which the immune system of the intestines is overactive. The goal of IBD treatment is not to immune suppress the patient, but rather to modify their overactive immune system so it’s under better control. We don’t think of our IBD patients at baseline as being immune suppressed. In fact, it’s the opposite. When we treat them effectively, we turn down the overactive immune system just enough so their body takes over, and we minimize their risk for infections.
Being on immune therapies for inflammatory bowel disease may increase the risk for some viral infections, but based on the information we have so far, we have not seen an increased risk of contracting COVID-19 in patients who are on the standard IBD therapies. Of the Crohn’s and ulcerative colitis patients we have seen who developed COVID-19, their course and recovery is exactly like what we’re seeing in the general population. Our general message to patients right now is to stay on your existing therapies and stay in remission. If you have any concerns, please make an appointment with your doctor and have a conversation about whether there might be any adjustments to be made.
What should I do if I have Crohn’s disease or ulcerative colitis and develop COVID-19 symptoms?
Patients with inflammatory bowel disease who develop COVID-19 will have the same symptoms as the general population of patients who don’t have IBD: fever, cough, respiratory symptoms (shortness of breath) or new onset diarrhea. Let your doctor know right away if you develop some of these symptoms or if you’re worried that you might have developed COVID-19.
If you have been diagnosed with COVID-19, based on the treatments you’re on, you may need to stop your therapy for a couple weeks. I don’t recommend that you stop your medicines without talking to your doctor first. Based on an international registry of IBD patients who developed COVID-19, there does not appear to be an increased risk overall in patients with IBD developing COVID-19 or having a different set of outcomes. Most IBD patients who develop COVID-19 won’t require hospitalization, but if they get sicker or develop more shortness of breath, it is important to know that we’re here to help.
Managing Crohn’s disease and Ulcerative Colitis During COVID-19 Pandemic
Should I keep my IBD appointments at this time?
Yes, you should keep your appointments, but do so virtually, if possible. Most of our IBD patients are having their appointments by telephone, MyChart, or video visits. We can handle many of your concerns and questions as well as your routine healthy follow up visits this way. If your IBD symptoms worsen and you are feeling sick, it is safe to come to an appointment at the clinic. We will work with you to find the best way to make an appointment happen. We have deferred most elective colonoscopies or other endoscopic procedures at this time. If you need a procedure because of something that’s time sensitive or essential in other ways for your management, we certainly are able to do that. The best thing to do is to call your doctor to find out what options are available for you.
If I am currently receiving infusion treatment for IBD, is it safe to go to an infusion center?
If you know that your infusion center is following proper safety protocols, then you should keep your appointments and get treatment. The University of Chicago Medicine is following safety protocols including screening patients for any known contacts with COVID-19 and any COVID-19 symptoms, spacing patients at least six feet apart and having a single provider working with each patient to limit exposure. All providers are wearing masks and gloves and offering those to the patient if they don’t already have them. After a patient has received their infusion, the chair and the surrounding area is appropriately cleaned.
Delaying infusible therapies or other treatments can lead to relapse and loss of response to the drugs.
Which IBD medications suppress the immune system? Is it safe to take these medications?
The medications we used to treat inflammatory bowel disease include a variety of therapies that work by different mechanisms or target different parts of our immune system. Sometimes we recommend immune modulator therapies called thiopurines or azathioprine and 6MP, or another medicine called methotrexate.
More recently, we have a variety of biological therapies which target different components of the immune system. A class of therapies called anti-TNF treatments focus on an inflammatory protein called TNF or tumor necrosis factor, which is elevated whenever somebody has an infection or overactive immune response. Anti-TNF drugs such as Remicade, Humira, Cimzia or Simponi are recommended to be continued at the current time.
Another drug called Entyvio targets the white blood cells that might be on their way to the bowel, blocking them from getting out of the blood vessels into the intestines. This is a more selective therapy in that it only works on the intestinal immune system, and therefore, the risk for infection might be lower than with anti-TNF and other treatments.
Lastly, we use a treatment known as Stelara, which targets two other inflammatory proteins that tend to be elevated only where there is inflammation in your body. This is a more selective treatment, but it still works on the entire body.
The goal of these therapies is not to suppress the immune system so patients are more susceptible to infections, but rather, to control the overactive inflammation of the bowel and let the body heal itself.
The general message regarding all of these therapies is that if you are in remission and the treatment you’re on is working for your Crohn’s disease and ulcerative colitis, you should stay on that therapy during the COVID-19 pandemic. We recommend that you continue to communicate with your health care team about any additional changes that might be necessary. For most patients, we are not recommending that they stop treatments. It is important to remember that these treatments are keeping your IBD under control. If the IBD becomes active, we may recommend corticosteroids like prednisone, however they can increase your risk of infections. This is why we want our patients to do their best to stay in remission. We recommend patients stay home as much as possible, wash hands frequently and follow any guidelines from our public health officials, such as the Centers for Disease Control and Prevention (CDC).
Should I be concerned about a supply shortage of IBD medications?
No. We have assurances from the pharmaceutical companies that there is a sufficient supply of medicine available. We recommend that patients with Crohn’s disease or ulcerative colitis stay on their medication schedule and refill their prescriptions appropriately.
Should I take supplements like vitamin c or zinc to help prevent coronavirus?
At this time, I would advise against taking additional supplements, such as extra vitamins or zinc to prevent a viral infection. There is no data to support their effectiveness and starting a new supplement might cause other side effects.
How do I know the difference between an IBD flare-up vs. COVID-19?
It may be hard to tell the difference between a flare up and COVID-19 infection because their symptoms can be similar. Loss of appetite, abdominal discomfort, more frequent bowel movements or loose stools are symptoms of both conditions.
We have testing options that do not require an in-person visit. These simple tests can help identify the cause of your symptoms.
What should I do if I think I’m having an IBD flare-up?
We have treatments available that are safe to start even while this pandemic is going on. There’s guidance that we’ve developed and published that will give people more information about which treatments to use and when to use them. If a patient has more severe inflammatory bowel disease, the usual treatments we use for IBD are safe and appropriate to be used in this setting. Patients shouldn’t ignore their IBD symptoms or any other digestive symptoms. Keep in touch with your physician to get it back under control quickly. The last thing we want is for patients to be living with these symptoms and afraid to notify their doctor or come to the clinic.
Any advice for essential workers with IBD who are unable to work from home?
We know that there are a lot of IBD patients who are essential workers right now and can’t work from home. It is important for these patients to recognize their likelihood of exposure and increased chance of contact with COVID-19-positive patients. For example, paramedics, doctors, nurses, technicians, respiratory therapists and pharmacists who are interacting with patients with COVID-19 have a high risk of exposure and should make sure they protect themselves as much as possible.
The advice we’ve been giving the general public should be followed the same by IBD patients. This includes social distancing, washing hands, cleaning surfaces and staying at home when possible. We also recommend keeping in touch with your doctor to know you are in remission and making sure your medications are being managed properly.
Are there extra precautions that pregnant women with IBD should be taking during the COVID-19 pandemic?
We’ve learned some information about COVID-19 in pregnant women, which applies to pregnant patients with Crohn’s disease or ulcerative colitis as well. We have seen that women who are pregnant and develop COVID-19 recover similarly to the general population. Although their babies might be born a bit early or a little underweight, for the most part, the babies seem to do well.
At this time, we have not seen cases of pregnant women becoming infected with COVID-19 in the first trimester. The data we have from prior coronavirus epidemics and other types of infections suggest patients may be fine. Because this is a novel coronavirus, we still need to monitor those patients carefully.
We recommend that our pregnant patients with inflammatory bowel disease make sure they’re staying in remission from their IBD. Stopping their IBD therapies could cause a relapse and would require hospitalization which may increase their risk of exposure to COVID-19. We also know that when IBD is in remission, the baby and mother both stay healthy. It is important that our IBD patients who are pregnant take extra precautions and follow strict social isolation. That means in addition to staying home, they should also restrict visitors from entering the home. If pregnant patients with IBD need to go out to the grocery store, they should wear a mask and gloves, and carefully wash their hands, as we’re recommending to everybody. We don’t have data yet to say that pregnant patients with IDB have more to worry about, but we want them to be extra careful.
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SUPPORTING EXAM STRESS and Kids going back to School.
Tests and exams can be a challenging part of school life for children and young people and their parents or carers. But there are ways to ease the stress.
Watch for signs of stress
Children and young people who are stressed may:
- worry a lot
- feel tense
- have headaches and stomach pains
- not sleep well
- be irritable
- lose interest in food or eat more than normal
- not enjoy activities they previously enjoyed
- be negative and have a low mood
- feel hopeless about the future
Having someone to talk to about their work can help. Support from a parent, tutor or study buddy can help young people share their worries and keep things in perspective.
Encourage your child to talk to a member of school staff who they feel is supportive. If you think your child is not coping, it may also be helpful for you to talk to their teachers.
Try to involve your child as much as possible.
Make sure your child eats well
A balanced diet is vital for your child’s health, and can help them feel well during exam periods.
Some parents find high-fat, high-sugar and high-caffeine foods and drinks, such as energy drinks, cola, sweets, chocolate, burgers and chips, make their children hyperactive, irritable and moody.
Where possible, involve your child in shopping for food and encourage them to choose some healthy snacks.
Read more about healthy eating for teens.
Help your child get enough sleep
Good sleep improves thinking and concentration. Most teenagers need 8 to 10 hours’ sleep a night. Learn more about how much sleep children need.
Allow half an hour or so for your child to wind down between studying, watching TV or using a computer and going to bed, to help them get a good night’s sleep.
Cramming all night before an exam is usually a bad idea. Sleep will benefit your child far more than a few hours of panicky last-minute study.
Be flexible during exams
Be flexible around exam time. When your child is revising all day, do not worry about household jobs left undone or untidy bedrooms.
Staying calm yourself can help. Remember, exams do not last forever.
The Family Lives website has more about coping with exam stress.
Help them study
Make sure your child has somewhere comfortable to study. Ask them how you can support them with their revision.
Help them come up with practical ideas that will help them revise, such as drawing up a revision schedule or getting hold of past papers for practice.
To motivate your child, encourage them to think about their goals in life and see how their revision and exams are related to them.
Talk about exam nerves
Remind your child that it’s normal to feel anxious. Nervousness is a natural reaction to exams. The key is to put these nerves to positive use.
If anxiety is getting in the way rather than helping, encourage your child to practise the activities they’ll be doing on the day of the exam. This will help it feel less scary.
For example, this may involve doing practice papers under exam conditions or seeing the exam hall beforehand. School staff should be able to help with this.
Help your child face their fears and see these activities through, rather than avoiding them.
Encourage them to think about what they know and the time they’ve already put into studying to help them feel more confident.
Encourage exercise during exams
Exercise can help boost energy levels, clear the mind and relieve stress. It does not matter what it is – walking, cycling, swimming, football and dancing are all effective.
Activities that involve other people can be particularly helpful.
Support group Childline says many children who contact them feel that most pressure at exam time comes from their family.
Listen to your child, give them support and avoid criticism.
Before they go in for a test or exam, be reassuring and positive. Let them know that failing is not the end of the world. If things do not go well they may be able to take the exam again.
After each exam, encourage your child to talk it through with you. Discuss the parts that went well rather than focusing on the questions they found difficult. Then move on and focus on the next test, rather than dwelling on things that cannot be changed.
Make time for treats
With your child, think about rewards for doing revision and getting through each exam.
Rewards do not need to be big or expensive. They can include simple things like making their favourite meal or watching TV.
When the exams are over, help your child celebrate by organising an end-of-exams treat.
When to get help
Some young people feel much better when exams are over, but that’s not the case for all young people.
Get help if your child’s anxiety or low mood is severe, persists and interferes with their everyday life. Seeing a GP is a good place to start.
Some basic rules coming up to exam time
A quiet place to study – A suitable environment to study is important to help concentration levels.
A balanced diet – Good nutrition is essential at any time of year, but especially during exam time. Batch cook some healthy meals and stock up on nutritious snacks. Having some of the student’s favourite dinner to hand is important too.
Omega 3 is essential to fuel the hard-working brain at this time. Keep brain and vision in tip top shape by making sure to top up your good fats daily. Consider taking Cleanmarine® Krill Oil High Strength. It contains 590mg of concentrated, high strength Omega 3 Krill Oil. This concentrated formula of EPA, DHA, Astaxanthin and Choline provides the essential fatty acids required for the normal function of the heart, brain and vision. DHA contributes to the maintenance of normal brain function and vision, the beneﬁcial eﬀect is obtained with a daily intake of 250mg. Also eating 2 – 3 portions of oily fish a week will provides more essential fats for your body. Examples include salmon, mackerel and herring. Easy to cook in steam parcels in the oven with garlic, lemon and oil.
A good night’s sleep – Studying all night may seem like a good idea but if your child doesn’t get enough sleep, they are more likely to forget the information or under perform. When your mind is buzzing with exam questions, quotes and scientiﬁc theories, having something to help you switch oﬀ, relax and support deep sleep is a must. Try melissa-dreams which contains all-natural ingredients including the herbs lemon balm (Melissa oﬃcinalis) and Chamomile in combination with selected B-vitamins, Magnesium and the amino acid L-theanine. Magnesium contributes to a reduction of tiredness and fatigue while vitamins B6 and B12 contribute to the normal function of the nervous system. With no drowsiness or side eﬀects the next day, Melissa Dream helps you to wake up rested and full of energy.
Exercise – Even a 20-minute walk will help your child to relax and destress their mind, this will also help oxygenate the entire body.
Stress is the biggest obstacle to overcome. It’s so important to get enough B vitamins in foods like broccoli. Kale, spinach. Getting your 5-a-day is bound to be the least of your worries as exam time approaches; ironically this is when your nutritional and energy needs are at their highest. Make sure you keep your nutrient and energy levels up with One Nutrition® Organic Power Greens. This is a unique combination of nature’s ﬁnest green foods including kale, broccoli, spirulina, wheat grass and barley grass juice powders in a handy capsule or powder to add to your morning smoothie.
Take time out to do something you love such as walking your dog, reading a magazine, chat online to your best friend. Journaling is also therapeutic, to put your thoughts and feelings onto paper. Try family time such as playing a board game to distract your mind from the books for a while.
Don’t forget to celebrate – when the exams are over, go out and celebrate together, hopefully everything will be back to normal by then.
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Can vitamin D really prevent Covid-19? Here’s what the evidence says.
Vitamin D supplement sales have soared amid the pandemic as people try to curb their risk of contracting the novel coronavirus—but some experts are urging caution, noting that not enough research has been done to establish a definitive relationship between taking the supplement and fending off Covid-19.
What the research says about vitamin D and Covid-19
According to Sabyasachi Sen, a professor of endocrinology and medicine at George Washington University (GW), deficiencies of vitamin D are “not rare” and are especially common in older adults, obese people, and people with darker skin—some of the same populations most affected by Covid-19.
While vitamin D is known for protecting bone health, it also helps with the immune system, Sen said. It’s believed that vitamin D improves the function of certain cells, including T cells, which fight off pathogens and can assist in modulating inflammatory responses.
In addition, Sen continued, research has found vitamin D deficiencies have been associated with an increased risk of infection. “Now, what is unknown is whether it’s a cause and effect rather than an association,” he said.
According to the Washington Post, researchers studying the relationship between vitamin D and Covid-19 outcomes are interested in precisely that question: whether there’s a cause and effect relationship, or merely an association.
For example, one study, published in JAMA Network Open, looked at the health records of 489 people in Chicago and found patients with a vitamin D deficiency in the year prior to testing for Covid-19 were 77% more likely to test positive for the disease than those with normal vitamin D levels. Taking a converse approach, another study looked at a small group of Covid-19 patients in Italy who had been hospitalized with acute respiratory failure and found that 81% of them had a vitamin D deficiency.
Meanwhile, an experimental study in France at a nursing home with 66 people found that taking vitamin D supplements was “associated with less severe Covid-19 and a better survival rate.” Similarly, a study in South Korea of 200 people found that a deficiency of vitamin D could “decrease the immune defenses against Covid-19 and cause progression to severe disease.” And a small study in Spain involving 76 hospitalized Covid-19 patients found that those treated with calcifediol—an activated version of vitamin D, distinct from the over-the-counter supplement—seemed to curb the severity of the disease.
On the flipside, however, a recent paper considered by the National Institute for Health and Care Excellence in the United Kingdom looked at vitamin D levels from up to 14 years ago and didn’t find any correlation between vitamin D levels and Covid-19 mortality. And while the lead author of that study has in other papers called for further research on the link between vitamin D and Covid-19 outcomes, the researchers concluded, “For now, recommendations for vitamin D supplementation to lessen Covid-19 risks appear premature and, although they may cause little harm, they could provide false reassurance leading to changes in behaviour that increase risk of infections.”
Similarly, a double-blind randomized controlled trial of 240 patients in Brazil, which has yet to be peer-reviewed, found that one large dose of vitamin D didn’t reduce hospital stay length or mortality rates among patients with a severe case of Covid-19 compared with those in a placebo group.
Correlation—not necessarily causation
“We do know that people who have lower blood levels of vitamin D tend to have a higher risk of being infected with Covid-19 and having severe Covid-19 illness,” JoAnn Manson, chief of the Division of Preventive Medicine at Brigham and Women’s Hospital, said. “But as we say in epidemiology, ‘Correlation doesn’t prove causation.’ We don’t know for sure that the low vitamin D level is causing an increased risk of Covid-19.”
According to Natasha Chida, an infectious disease expert and assistant professor of medicine at Johns Hopkins University, people who have a vitamin D deficiency typically have other health factors that could affect how likely they are to develop a severe case of Covid-19—and people who do develop diseases such as Covid-19 often experience a drop in vitamin D levels.
“Unless you take into account all those factors and separate all those out and look at just vitamin D … it’s really hard to make any inferences about what vitamin D is doing here,” she said.
Chida added that there’s “some biologic plausibility” that vitamin D could help Covid-19 patients. “It’s just that despite years of research into the use of vitamin D in respiratory tract infections, there still hasn’t really been a clear, slam-dunk answer that there’s a benefit.”
Research into the relationship is ongoing, however. According to the Washington Times, about 70 clinical trials assessing vitamin D and Covid-19 have been filed in the U.S. National Library of Medicine database.
Should you take vitamin D supplements?
As of now, experts say people who know they have vitamin D deficiencies should continue their treatment, and those thinking about taking supplements should talk to their health care provider first, given there’s no firm evidence that vitamin D supplements curb people’s risk of infection or serious Covid-19 illness.
“People should be wary of taking mega doses of vitamins or unproven interventions specifically for Covid-19, because we don’t have good quality data yet to suggest that this is of any help,” Hana Akselrod, an infectious disease specialist at GW, said.
Instead of supplements, people can add more vitamin D to their lives by being outdoors for 15 or 20 minutes a day, Akselrod added. And some foods, such fatty fish or fortified dairy products, could also improve vitamin D levels, Manson said.
“There are all of the positive confluences around nutrition and outdoor exercise that aren’t just limited to the number of how many units of vitamin D you get every day,” Akselrod said. “And on top of that, people absolutely need to continue all the other safety precautions, like masking and safe distancing and avoiding gatherings, because we’re in the most dangerous phase of the pandemic yet”.
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