Transcript Dr. Stein`s Presentation.

Philip Stein
Nov 16, 2016
Program or procedure planned to
-prevent illness
-maintain maximum function
-promote health
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Things to do to further decrease chance
complications of the medications and the
disease itself
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Your gastroenterologist is not your:
-primary care physician
-pediatrician
-ob-gyn
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Many patients with IBD take medications
which suppress the immune system. This
could include steriods, methotrexate,
6mp/imuran, infliximab, adalimumab.
Risk of having more severe illness from
bacterial or viral infections.
When immune system is not working at its
full capacity. You want to aid it and make it
more effective if there is a preventable
disease.
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The best time to vaccinate is at diagnosis.
Once you start treatment such as biologics,
immunomodulators, steriods the chance of
response decreases as well as
contraindications such as for live vaccines
may become present
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Varicella (chicken pox)- Can check blood
work to see if your body is producing an
antibody for protection. If on
immunosuppression should not be given
MMR (Mumps, Measles and Rubella) also
contraindicated in immunocompromised
patients and those planning to start
immunosuppressants within 3 months
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Influenza- 1 dose to all patients (not
intranasal live vaccine) every year
HPV- Related to cervical and anal cancer. 3
doses approved for females and males ages
9-26.
Pneumococcal - Vaccinate if not previously
vaccinated. If immunocompromised perform
one-time revaccination after 5 years.
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Hepatitis B- Testing should be done for this
prior to starting an Anti-TNF. If non-immune
consider vaccination series with attenuated
hepatitis B vaccine.
Meningococcal Meningitis - Vaccinate at-risk
patients (college students) if not previously
vaccinated
Why is bone health important in IBD?
Active IBD can affect the normal development of
the skeleton in many ways. It can:
-slow down bone growth and affect the structure
of the bones.
-delay the onset of puberty, which is a time of
rapid accumulation of bone mass.
-decrease energy, physical activity and muscle
mass.
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All of these are important for normal bone
development.
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Children with active IBD can have a decrease in
appetite, which can limit the availability of nutrients
that are the building blocks to form muscles and
bones.
Can reduce their intake of milk, cheese and yogurt,
spend more time indoors and use sunscreen on the
skin. This may limit the amount of vitamin D and then
affect how the body can absorb calcium from the
diet.
Extensive inflammation of the small intestine or
surgical removal of part of the intestines can affect
how many nutrients are absorbed that are important
for the formation of bones and muscles.
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Chronically active disease
Malnourished (low body mass index), who
have delays in growth and puberty and low
levels of blood proteins (albumin) can have
thinner, shorter bones.
Treatment with steroids for more than 3
months can also affect bone formation and
growth.
Family history of osteoporosis
Early menopause
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Most available method is called bone density scan
(also referred to as dual X-ray absorptiometry or
DXA).
The bone density test takes a whole body X-ray with
very low dose of radiation.
10 minutes to obtain this special X-ray,
Need to be very still for the bone density scan to be
accurate.
Completely painless. The X-ray gives information
about the amount of bone mineral, fat and muscle
(fat-free) mass in the body.
Low density puts one at higher risk having fractures
of long bones or the spine with low trauma
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Discuss the results with your doctor.
To improve your bone mineral density may include:
-improving the control of the IBD without using
steroids
-optimizing nutrition
- supplementing calcium and vitamin D (if the
vitamin D level is low)
- encouraging exercise that involves walking, running
and jumping (called weight-bearing exercise).
- May be helpful helpful to partner with a
endocrinologist to make sure that the low bone mass
is not secondary to a condition unrelated to IBD and
to consider other treatment options that act on the
bone to make bones stronger.
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Mesalamines-Periodic kidney function
monitoring with blood and urine tests
Corticosteroids-Bone Health issues, blood
sugar, weight, cholesterol
Thiopurines-TPMT, CBC and Liver tests prior
to initiating therapy and then routine CBC,
liver and renal function monitoring during
therapy
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Methotrexate –CBC, liver and kidney function
prior to initiating therapy
Routine monitoring CBC, liver and renal
functioning
Avoidance of alcohol
Pregnancy prevention for a female patient
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Anti-TNF
Tb and hepatitis B testing prior to initiating
therapy
Tb with skin test called ppd or QuantiFeronT Gold assay
High risk- chest xray
Consider annual Tb skin test annually
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Current smokers have twice the risk of developing
Crohn’s disease than those who never smoked.
Crohn’s disease- smoking increases the risk of flares,
and increases risk of requiring surgery.
If you currently smoke, consider joining a smoking
cessation program or talk with your doctor about
anti-smoking agents
Passive smoke exposure (being exposed to tobacco
smoke) also increases risk of disease or more severe
disease. Caregivers of pediatric patients with Crohn’s
disease should stop their tobacco use.
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Increased risk of colon cancer in anyone with IBD
involving the colon. People with ulcerative colitis
and those with Crohn’s disease of the colon
(Crohn’s colitis) have increased risk of colon
cancer
After colitis is first diagnosed, the risk of colon
cancer appears to be similar to that of people
without colitis for the first 8 years. Then around
8-10 years after IBD diagnosis, the risk of colon
cancer starts to increase, and increases more
quickly over time after that.
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Evidence to suggest that the risk of colon
cancer may be lower in people whose colitis
is better controlled.
No conclusive evidence to say that one
particular treatment is better than another for
preventing colon cancer.
Even with good control risk of colon cancer is
still higher in people without IBD.
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A well-rounded diet, with lots of fruits and
vegetables is associated with a reduced risk of
colon cancer in people. High fiber diets appear to
have a benefit as well (check with your doctor)
In the long-term, eating lots of red meat or
processed meats seems to be associated with an
increased risk of colon cancer. (Some
recommend limiting to 1-2 times per week).
Low vitamin D levels have been associated with
increased bowel inflammation in IBD and with
increased risk for colon cancer in general
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Tobacco exposure is known to increase the
risk of colon cancer in addition to other
cancers.
Regular physical activity and exercise are
associated with a lower risk of colon cancer
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If someone develops colon cancer, or has pre-cancerous
growths in the colon - much more treatable if caught
early.
Most colon cancers that are caught early are completely
treatable which is why screening for colon cancer is so
important
Screening colonoscopies start 8-10 years after the
diagnosis of colitis has been made.
Debate about how often to have screening colonoscopies
after that. If there is active inflammation, everyone agrees
that patients should have the next screening colonoscopy
1-2 years later. If in remission, may be able to be slightly
less often
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PSC is a disease of the liver that causes
scarring of the bile ducts. For people who
have both colitis and PSC, the risk of colon
cancer is much higher than others with colitis
who do not have PSC.
For this reason, the recommendation is to
start screening colonoscopies 1-2 years after
diagnosis and continue screening every 1-2
years
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After removal the colon with surgery it is rare to
get colon cancer.
Used to be more common but now with the
availability of more effective medicines it is not
done as often
It remains true that removing the colon is the
ultimate form of colon cancer prevention.
It is a major decision, and may be considered for
many different reasons, in people with IBD. There
may be risk and benefits and should be made
with careful thought and discussion with your
doctor.
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Cervical cancer is increased in women with
IBD.
It is unclear if this risk is inherent to having
IBD, or if the increased risk is medication
related.
Vaccine available to prevent human papilloma
virus (HPV), the virus that causes most forms
of cervical cancer.
Annual PAP smears after 21 if
immunocompromised
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Risk of skin cancer is increased in everyone with
IBD - important to be aware of how to prevent it.
Azathioprine (Imuran®, Azazan®) and 6mercaptopurine (6MP or Purnethal®) are both
associated with an increased risk of NMSC.
Ultraviolet light is the main thing that injures the
skin triggering skin cancer.
Avoiding excessive ultraviolet light exposure is
the best way to prevent skin cancer. The two
biggest source of ultraviolet light are sunlight
and tanning beds.
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To prevent skin cancer associated with sun
exposure, using sunscreen with an SPF of 30
or above is recommended. Sunscreen should
be re-applied every 2 hours with ongoing sun
exposure.
Some recommend yearly dermatology visit
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Chronic illness such as inflammatory bowel
disease (IBD) face more challenges and stress
than others
Must cope with a complicated medication
regimen, possible side effects of medications,
frequent clinic visits, possible hospitalization,
bloodwork, possible surgery and children may
have poor growth, delayed puberty.
Several studies have shown that as many as 25%
of adolescents with IBD are depressed, and when
depressed, their anxiety may increase as well
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It is important to understand there is support
from the health care team, as well as family
members, and friends.
Screening for depression should be
performed regularly and more frequently
when there is a concern about mood, or
change in disease status.
Referral and appropriate treatment should be
done as needed.
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Routine lab monitoring will vary depending
on your particular disease and individual
medications. Common labs that require close
monitoring include:
CBC (white blood cells, platelets, and
hemoglobin/hematocrit to check for anemia)
liver function tests including bilirubin
inflammatory markers called ESR and CRP,
albumin
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Being proactive in your health is important
Easy to forget about when feeling well
Take advantage of opportunities to prevent
infection with vaccines and work to prevent
or screen for early detection of cancer some it
may be caught when treatable