Health Maintenance in the IBD Patient

John D Betteridge

Health Maintenance in IBD

What We Will Cover

• Vaccines– Live vs. Inactivated

• Other than Vaccines– Dysplasia/Cancer

• Colon, Cervical, Skin

– Bone density– Smoking Cessation– Depression Screening

What We Won’t

• Related Diseases/ EIM’s– VTE, Arthritis, Autoimmune

• Medication Side Effects– Direct, Autoimmune

• Micronutrients– Iron, B12, Vitamin D

Health Maintenance in IBDCase Presentation

• 24 year old woman, diagnosed with Ulcerative pan-colitis, 2 years ago. 4 courses of Prednisone in 20 months. Takes Mesalamine daily, she admits to irregular follow up when she felt well. She presented for second opinion and then colonoscopy with persistent symptoms of diarrhea with blood and worsening pain.

• Now she is back in the office to discuss steroid sparing immunosuppressive therapy.

• What can we tell her about her other

health needs?

Case PresentationThings to Consider in the IBD Visit

• Help her feel well, improve long term prognosis, i.e. surgery/hospitalization

• Risk for infection• Bone health• Smoking• Risk for cancer• Depression• Iron deficiency, Vitamin D deficiency

Health MaintenanceThe Problem

• IBD Patients get fewer health services than other primary care patients

• Indicated services for IBD patients often delivered later to less effect

• IBD patients seen less often in primary care

Kane S et al. Inflamm Bowel Dis, 14 (2008), pp. 253–258

IBD and Immunosuppression

• Infection is the most common side effect of immunosuppressive therapy in IBD

• Many infections potentially preventable with vaccination

• Risk of infection increases and response to vaccine decreases with number of immunosuppressive therapies

What is Immunosuppressed?

• > 19mg Prednisone more then 14 days

• Treatment dose of thiopurine, biologic, or methotrexate

• 3 months after cessation of above

Sands BE, et al. Inflamm Bowel Dis 2004;10:677-92

Vaccines• Who is responsible for vaccinating IBD patients?

– 82% of GI think it is PCP responsibility– 29% of Family Physicians comfortable directing

vaccination in these patients

• CDC: Vaccinate – Tdap, HPV, Influenza, Pneumococcus, HBV, HAV,

Meningococcus, MMR, Varicella, Shingles

• Are they effective and safe? Live virus?

Selby L, Hoellein A, Wilson JF. Dig Dis Sci 56:819-24.S.K. Wasan, J.A. Coukos, F.A. Farraye. Inflamm Bowel Dis, 17 (2011), pp. 2536–2540

VaccineEfficacy

Vaccines SafetyIBD clinical score activity CD (N390) UC (N158) IC (N6)

HBI at baseline, median (IQR) 1 (0;3) na na

PMS at baseline, median (IQR) na 1(0;2) 1 (0;2)

Absence of flare, n (%) 377 (96.7) 151 (95.6) 5 (83.3)

Rise of 3 points, n (%) 1 (0.2) 4 (2.5) 0 (0)

Rise of 4 points, n (%)) 3 (0.8 1 (0.6) 1 (16.7)

Rise of > 4 points, n (%) 9 (2.3) 2 (1.3) 0 (0)

Rahier JF et al ut 2011; 60:456

VaccinesLive Vaccines

• In general, are contraindicated in immunosuppressed individuals– LAIV, Yellow Fever, BCG, OPV, Small Pox

• “Weigh the risk of disease against risk to the individual”- CDC (www.CDC.gov) • Varicella, MMR, HZV

Live VaccinesVaricella/HZV

• MMR– If needed in an adult give at least 6 weeks

before immunosuppressive tx

• 2008 CDC/ACIP Guidelines– Give HZV/Varicella if:

• MTX < 5mg/kg/wk• AZA <3.1 mg/kg/d• 6MP <1.5 mg/kg/d

If anti-TNF, wait at least 30 days

Harpaz et al. MMWR Recomm Rep 2008

Live VaccineCan Household Contacts Get Live Vaccine?

Safe

• MMR• Varicella (generally ok but

watch for rash)• Rotavirus• HZV

Avoid

• Live Influenza Virus– Virus can shed for up to 3

days

• Oral Polio Vaccine• Small pox

VaccinesSummary

Prepare to Give

• Tdap• Influenza• Pneumococcus• Hepatitis A, B• Meningococcus

Give 4-12 weeks before Tx

• MMR• Varicella• Zoster

• Earlier the Better!

Bone Health

• Incidence of osteoporosis in IBD is 10-15% across multiple studies

• Osteopenia in one study of 2035 IBD patients was identified in 48%

• AGA/ACG Guideline– Screening for all IBD patients with 1 of 5

• Postmenopausal, > 60, ongoing corticosteroids or cumulative use of > 3 months, Hx of low trauma fracture

Lichtenstein GR. Inflamm Bowel Dis 2006;12: 797

Bone HealthOther High Risk

• Active Crohn’s, previous long term activity• Intestinal resection (small bowel)• Smoking

• ECCO guideline– All active Crohn’s patients or long term activity– Corticosteroids > 3 months

Van Asche et al 2010: ECCO guideline

Cervical Cancer

Kane et al. Amer J Gastro 2008

Mayo: IBD and Immunosuppressed IBD women have more cervical dysplasia

Cervical Cancer

St Marks: IBD women with no more Risk for Cervical Dysplasia than Control

Lees et al. Inflamm Bowel Dis 2010

Cervical Dysplasia

• Large nested cohort study of 19,662 abnormal Pap smears in Canada– No association with IBD alone– Increased risk if Crohn’s and OCP’s– Biggest risk in those receiving corticosteroids

and immunosuppressant prescriptions

Singh et al. Gastroenterology 2009

Skin Cancer• Thiopurine Use > 365 days is Risk Factor for

Non-Melanomatous Skin Cancer– Harm Ratio of 3.94 if discontinued– Harm Ratio of 5.90 if continued

• Caution patients about sun exposure, consider yearly skin exams

Peyrin-Biroulet et al. Gastroenterology 2011

Colon Cancer

• AGA/CCFA/ACG/ASGE Expert Panel • Recommendations:

– Initial surveillance examination after 8-10 years of UC pan colitis, Left sided colitis, Crohn’s colitis

– Repeat endoscopy every 2 years until 20 years of disease then yearly intervals should be considered

– PSC patients should have endoscopy to determine if IBD has developed. PSC + IBD Colitis should have index endoscopy at time of IBD diagnosis

Risk of CRC in UC Pancolitis• 95 cancer cases per 100,000 population

• Meta-analysis of 116 worldwide studies assessing the risk of CRC in UC

• Prevalence of CRC is 3.7% overall and 5.4% pancolitis

• Cumulative Risk of developing CRC:– 2% @ 10yrs, 8% @ 20 yrs, 18% @ 30 yrs

Eaden etal. Gut 2001; 43:526-535Söderlund S et al. Gastroenterology 2009

Risk in Crohn’s Disease

• Populations studies show same risk as UC with similar disease extent. Treat them the same– Sweeden

• RR of CRC in CD is 2.5 and 5.6 if CD of colon only

– Canada• Increased RR of CRC for CD (2.64) and UC (2.75)

Ekbom A et al. Lancet 1990; 336:357-9Bernstein CN et al. Cancer 2001; 91:854-62

Colon Cancer

Ulman T et al. Gastroenterology 2013

Smoking Cessation

• Difficult topic often overlooked by GI’s and PCPs alike– Smokers have more Crohn’s and worse Crohn’s:

↑↑ debilitating course (steroids, hospitalizations, surgery, medical disability)

– UC patients may smoke to help symptoms which has long term negative health effects

Depression

• Major Depression is twice as likely in IBD cohorts

• Incidence estimated at 15-30% of IBD patients

• Single center study:– Crohn’s patients with depression had longer hospital

stays, more ER visits, and significantly higher costs compared to Crohn’s patients without depression

Sinclair et al. Gas Clin N America; 2012Cunningham and Betteridge; DDW 2015

Depression

• Simple screening:– In past month, have you felt down depressed

or hopeless?– In past month, have you felt little interest in

doing things?

Health Maintenance in IBD

• Three Things I want for my IBD Patients:– 1. Live a normal healthy life– 2. As often as possible, achieve #1 without

corticosteroids– 3. Keep a close eye on them for complications/flares

of disease and complications from the medications I give them to treat the disease.

– It can be difficult to get to # 3, but the more we try the healthier our patients will be.

QUESTION

Questions?