Transcript What We Will Cover

Health Maintenance in the IBD
Patient
John D Betteridge
Health Maintenance in IBD
What We Will Cover
• Vaccines
– Live vs. Inactivated
What We Won’t
• Related Diseases/ EIM’s
– VTE, Arthritis, Autoimmune
• Other than Vaccines
– Dysplasia/Cancer
• Colon, Cervical, Skin
– Bone density
– Smoking Cessation
– Depression Screening
• Medication Side Effects
– Direct, Autoimmune
• Micronutrients
– Iron, B12, Vitamin D
Health Maintenance in IBD
Case 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 Presentation
Things 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 Maintenance
The 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
Vaccine
Efficacy
Vaccines Safety
IBD 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
Vaccines
Live 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 Vaccines
Varicella/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 Vaccine
Can 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
Vaccines
Summary
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 Health
Other 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
Mayo: IBD and Immunosuppressed IBD
women have more cervical dysplasia
Kane et al. Amer J Gastro 2008
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
Söderlund S et al. Gastroenterology 2009
Eaden etal. Gut 2001; 43:526-535
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; 336:357-9
Bernstein 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; 2012
Cunningham 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?