In Focus

Health Maintenance and Preventive Care in Patients with Inflammatory Bowel Disease


 

Inflammatory bowel disease (IBD) consists of two chronic inflammatory diseases, Crohn’s disease (CD) and ulcerative colitis (UC), as well as a small category of patients (~10%) who have atypical features called IBD-unclassified (IBD-U) or indeterminate colitis. The prevalence of IBD ranges from 0.3% to 0.5% overall in North America and Europe.1 In North America, the incidences of CD and UC are estimated to be 3.1 to 14.6 per 100,000 person-years and 2.2 to 14.3 cases per 100,000 person-years, respectively; similar rates are seen in Europe.2 However, incidences up to 19.2 and 20.2 per 100,000 for UC and CD, respectively, have been reported in Canada.3,4 The incidences of both UC and CD are increasing over time in Western countries and in rapidly industrializing countries throughout Asia and South America.5-8

Dr. Karen A. Chachu

Dr. Karen A. Chachu

With the increased incidence and advances in the treatment of IBD, many more patients are being treated with corticosteroids, immunomodulators, and biologics. Over time, there has also evolved an understanding of the importance of health maintenance in IBD patients, especially since patients with IBD receive fewer recommended preventive health services than general medical patients even though the use of immunosuppression is an argument for more attention to these issues.9 Gastroenterologists may see patients more frequently than their primary care provider (PCP) or PCPs may be unaware of the specific needs of IBD patients. Therefore, it is important that gastroenterologists are knowledgeable about the health maintenance recommendations that can be made to patients and to communicate these to PCPs. Recent society guidelines endorse the importance of this aspect of our practice.10 The discussion below highlights health maintenance issues that should be fundamental aspects of our IBD practices, however it does not address colon cancer screening and surveillance since these are beyond the scope of this article.

Influenza vaccine and pneumococcal vaccine

Influenza A and B outbreaks are commonly seen during the fall and early spring and risk factors for pneumonia and hospitalization include older age, chronic medical conditions, and immunosuppression. The CDC now recommend annual influenza vaccination for all individuals older than six months. For patients on immunosuppression, the vaccine administered should be the inactivated vaccine, as live attenuated vaccines should not be administered to these patients.

Copyright Shawn Rocco
Patients with IBD are also at an increased risk of bacterial pneumonia, the most common etiology of which is pneumococcal pneumonia.11 The Advisory Committee on Immunization Practices (ACIP) recommends that patients on immunosuppression receive a one-time dose of the pneumococcal conjugate vaccine PCV13, followed by a dose of the pneumococcal polysaccharide vaccine PPSV23 one year later (eight weeks at the earliest). A second dose of PPSV23 should be given five years later and a third dose after 65 years of age.

In IBD patients, the influenza and pneumococcal vaccines are both well tolerated without an increased rate of adverse effects over the general population and without an increased risk of IBD flares after vaccination.12 A common question for patients on biologic therapy is whether the vaccine should be timed at a specific point in the dose cycle. For infliximab, and likely other biologics, the timing does not change the vaccine immunogenicity and patients should be given these vaccines regardless of where they are in the cycle of administration of their biologic.13 In addition, there is significant response to influenza and pneumococcal vaccines in patients on combination therapy with immunomodulators and anti-TNFs and concerns about a lack of response to vaccines should not discourage vaccination since benefits are still acquired by patients even if immunogenicity is somewhat decreased.14,15

Other vaccinations

In addition to the influenza and pneumococcal vaccines, adult and pediatric patients with IBD should follow the ACIP recommendations for tetanus, diphtheria, pertussis (Tdap), Td boosters, hepatitis A, hepatitis B, human papilloma virus (HPV), and meningococcal vaccinations.16,17

Live vaccines including measles mumps rubella (MMR), varicella, and zoster vaccines are in general contraindicated in immunosuppressed patients on corticosteroids, azathioprine/6-mercaptopurine, methotrexate, anti-TNF, and anti-integrin biologics. An inactive varicella-zoster vaccine will likely be available in the near future and may obviate the need for the live vaccine, which is an important development given the increased risk of zoster in patients with IBD on immunosuppression.18

Osteoporosis screening

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Both men and women with IBD have an elevated risk of osteoporosis and osteopenia as well as elevated fracture risk.19 This is related to frequent chronic corticosteroid use, chronic inflammation (high disease activity), women with low BMI, smoking, older age (women > 65, men >70), terminal ileal disease or resection in patients with CD, and proctocolectomy and ileal pouch-anal anastomosis in patients with UC. The recommendations are to obtain baseline bone density evaluation only in patients with risk factors, including young patients since osteopenia can be present at a young age. If If osteopenia is noted, then calcium (1000-1200mg daily) and vitamin D (1000-4000IU daily) supplementation can be associated with improvement in osteopenia.20 If osteoporosis is noted, patients should be referred to rheumatology or endocrinology for evaluation for bisphosphonate therapy which is also associated with improved outcomes.21 Bone density testing should be repeated every two years in patients with osteoporosis on treatment and less frequently when there is improvement.22 Given the association of bone metabolism disorders with smoking, this is one more reason to encourage our patients to quit.

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