Preventive Care for Patients With Inflammatory Bowel Disease: Time for Action

David A. Johnson, MD


February 24, 2017

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Addressing Our Limitations as Preventive Care Providers

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

Primary care doctors are the ones that we typically assume are doing preventive care for our patients, but when it comes to inflammatory bowel disease (IBD), gastroenterologists are often the ones who serve as the primary care doctors for these patients. However, we are really not doing a very good job in this role, which is why I give kudos to the authors behind fantastic new guidelines for preventive care in our IBD patients that were just put out by the American College of Gastroenterology.[1]

A 2011 survey[2] looked at the knowledge base in gastroenterology regarding vaccine administration and found that approximately one third of respondents would have been inappropriately giving active attenuated vaccines to patients who are immunocompromised, and another one third were actually withholding inactive vaccines from people who were immunocompetent. There has really been a mix-up here.

Let's take it a step further and ask, who is responsible for primary care when it comes to vaccination? Most primary care doctors do not feel comfortable vaccinating patients on immunosuppressive therapy and instead feel that the gastroenterologist should assume this responsibility. Nonetheless, there is clearly a problem surrounding this issue.

The authors behind this outstanding document have several recommendations to guide such decisions. This is a must-read overview, but for now let's look at some of its highlights.

Adopting Successful Vaccination Protocols

First of all, the active effort for vaccinations should begin at the initiation of the diagnosis of IBD. When you see a new patient with IBD, it's time to start thinking about vaccination status right at that moment. Take a good history, do your serologic profiles, and vaccinate, vaccinate, vaccinate. Do everything you can upfront before they even get to the point of needing an immunosuppressive and a biologic therapy. That is the real take-home message from this overview.

There are vaccinations that are inactive, which we need to be better at administrating. The influenza vaccine and the pneumococcal vaccines are two such examples of inactivated vaccines, and we know that patients with IBD have an increased risk and susceptibility for both influenza and pneumococcus. The majority of influenza vaccines are inactive, though there is a live influenza vaccine with intranasal administration vaccine that should be done annually. Many of you may not recognize the pneumococcal vaccine, but there are actually two of those now. One is Pneumovax®, which is the 23-valent vaccine that has been standardized for a long time, and the other is Prevnar®, the 13-valent pneumococcus vaccine that should also be administered in your patients. In the treatment-naive patient, the Prevnar is given first and then followed at least 8 weeks after by the Pneumovax. The recommendations state that the Pneumovax should be repeated in 5 years and again at age 65 years, with patients put on monitoring for subsequent delivery of these vaccines. The pneumonia and influenza vaccines can be administered concomitantly, which would perhaps increase the compliance in those patients.

Turning toward the recommendation for other vaccines, routine screenings are standardly applied for our patients undergoing biologic therapy. We screen them for hepatitis B, but there is no reason that we should not be proactively screening these new IBD patients also for hepatitis A and vaccinating appropriately.

If the patient has also not had their tetanus vaccine, then they should really be given Tdap, which is a one-time dose, in recognition of the fact that pertussis is really creeping back into the adult recommendations. They should be boosted every 10 years with the tetanus diphtheria-type vaccination, as is considered standard.

Another consideration is to administer the human papillomavirus (HPV) vaccine, which we really need to be proactive about in our younger patients. The recommendation is for the HPV vaccine to be administered to males and females aged 11-26 years.[3] There is a very interesting section of this paper, written by Dr Sunanda V. Kane, which addresses the cervical cancer risks in women with IBD and, in particular, those on immunosuppressants. These patients need to be monitored closely on top of the fact that they are at increased risk if they have HPV. Nonetheless, the American College of Obstetricians and Gynecologists recommendations call for standard cervical cancer screening every 3 years. In the IBD patient on immunosuppressants, we need to now follow the recommendations that it is annualized. These are patients who really need to have that message driven home. We need to be referring those patients if they are not being routinely monitored by their gynecologist.

Keeping Vigilant for Common Comorbidities

The other area that this overview covers, and one in which we need to be proactive as well, is screening for osteoporosis. The authors recommend a screening initially at diagnosis of osteoporosis, as anywhere from 20% to 40% of patients with IBD actually have prevalent osteoporosis.[4,5,6] [Editor's note: According to the overview, the estimated range is that 14%-42% of persons with IBD have osteoporosis.] We need to be more proactive in recognizing this, in particular with patients initiated on glucocorticoid steroid therapy who need to be screened again and with some regularity periodicity going forward afterward.

The authors also drive home the point about skin cancer monitoring in our patients with IBD, as both Crohn disease and ulcerative colitis have an increased risk for not only melanoma but also nonmelanoma skin cancers. This is particularly a concern in those on immunosuppressants, though this is a general risk as well. The recommendation is that all patients with IBD be counseled about skin cancer risk, prevention with sunscreens and sun exposure reduction strategies, and self-examination techniques. The nonmelanoma skin cancer patients on immunosuppressants have a very sizeable increased risk and should be monitored by dermatologists. We know this from the immunosuppressioncardiac transplant literature that these patients have an approximately 30% chance of getting a skin cancer within 10 years, and if they have an initial skin cancer, the risk of developing a metachronous cancer within 5 years approaches 70%.[7,8] All of these patients should be monitored routinely by dermatologists, but they also need to be counseled about self-examinations. My routine is now just to refer my patients to have a dermatology examination once a year.

This overview also raises the idea that we can monitor our patients better for anxiety and depression. We are not always very good about taking a good history, nor do we have good tools in this area. I would drive home the idea of also taking a good sleep history, because anxiety and depression drive a lot of sleep disparity. In turn, we know that sleep disruption clearly has a strong concordance with aggravation of IBD, given that it upregulates a variety of things, like cytokines (eg, TNF-alpha) that may induce induction of primary disease or relapse or perpetuation of disease in those patients with active disease.

Take-Home Messages

The bottom line is that we need to be much more proactive. We need to be thinking about vaccination history and initiating vaccination strategies at the onset of a diagnosis of IBD. This overview is a must-read for everybody, and I would share that emphasis with everybody from your nurses to your phone attendants. People need to be aware of this. This is something that ought to be on your screen.

The Crohn's & Colitis Foundation of America (CCFA) provides two really useful checklists for patients with IBD that I would encourage you to look at, and perhaps pick one or both to build into your electronic medical records. The first is the cornerstone checklist, which we found to be incredibly valuable when it comes to the precautions when patients are on or off immunosuppressive therapies and the windows for vaccination for these patients. The other is CCFA's health maintenance checklist for adult IBD patients. Look at both these, pick one or both, but make sure to get this in your electronic medical record. It has to be on your screen for routine monitoring.

Kudos again to the authors behind this overview for providing us with such an invaluable resource. I learned a tremendous amount from this, and you will too. Share it with everybody who cares for your patients with IBD. If we want to make a difference, promoting preventive care is crucial in these patients.

I am Dr David Johnson. Thank you again for listening.


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