Hints for preventive care in inflammatory bowel disease

Age-appropriate, up-to-date vaccination is key.

Preventive care for inflammatory bowel disease (IBD) starts with “IBD HINTS,” according to CDR Manish Singla, MD, FACP, USN. That mnemonic, which stands for Immunizations, Bones, Dysplasia and Depression, Hepatobiliary, Infections, Nutrition, Tobacco, and Skin cancer, can help clinicians remember what to look for when they see a patient with IBD. He reviewed some of these factors at a Thursday-morning session on “Inflammatory Bowel Disease Potpourri.”

“Of course we begin with age-appropriate vaccination, which we should be doing for all of our patients,” said Dr. Singla, who is an assistant professor in the department of internal medicine at Walter Reed National Military Medical Center in Bethesda, Md. That includes influenza, meningococcus, MMR (measles, mumps, rubella), and Tdap (tetanus, diphtheria, pertussis).

In addition, patients with IBD have an increased risk for pneumonia, particularly if they're taking narcotics. With Crohn's disease, risk for invasive pneumococcal disease is very high in the first six months after diagnosis, and risk is probably highest in general in the years before IBD is diagnosed. Patients should receive the PCV13 vaccine, the PPSV23 vaccine eight weeks later, and the PPSV23 vaccine again at five years, Dr. Singla said. “We do that for all of our IBD patients regardless of whether or not they're on immunosuppression,” he said.

Hepatitis B status should be checked before beginning anti-tumor necrosis factor (TNF) therapy, which is associated with fulminant hepatitis B, Dr. Singla said. Those who are unvaccinated should get the three-dose series.

“In patients who are immunosuppressed, we check them for about a month or two after they're done with their series to make sure their titers are at the correct threshold,” he said. “If they aren't, we will redo it at the double dose of the vaccination.”

Some clinicians may choose to start with a double dose in patients who are already immunosuppressed, he noted.

Herpes zoster vaccine, if needed, should be administered 14 days before “high immunosuppression” with anti-TNF biologics or high-dose steroids, or three months after discontinuing that same immunosuppression, Dr. Singla noted. He reminded attendees that the live herpes zoster vaccine cannot be given to patients taking anti-TNF therapy.

The human papillomavirus (HPV) vaccine is probably underused in IBD patients, Dr. Singla said, and emerging data show that patients with Crohn's disease, especially perianal Crohn's disease, are at higher risk for anal HPV.

“This should be a shared responsibility between the gynecologist, the patient's gastroenterologist, and their internist, but seems to still fall by the wayside,” he said. He also noted that since abnormal Pap smears are more common in those who are immunosuppressed, they should get the test annually rather than every two to three years.

Patients with IBD, particularly Crohn's disease, are at very high risk for osteoporosis and osteopenia, Dr. Singla said. “We get them bone density screenings at diagnosis,” he said. Micronutrient screening should focus on vitamin B12 and vitamin D deficiency, as well as potentially low magnesium and zinc in patients with chronic diarrhea.

Anemia in patients with IBD “is actually a very big problem,” Dr. Singla said. “They come in and their low hemoglobin is actually a core predictor for disease.” Iron parameters should be checked every six to 12 months, and every three to six months in patients with active disease, he recommended. Patients with active Crohn's disease can be given erythropoietic agents, he noted, “although this I think might be overdoing it a little bit.” He recommended a low threshold for IV iron replacement in patients who have both irritable bowel syndrome and IBD, since it's associated with improved quality of life and no worsening of disease activity.

Annual skin cancer surveillance is recommended for IBD patients, and if that's not possible, patients can go to a one-time appointment where they learn how to do their own screenings annually at home and measure, photograph, and track their moles digitally. “This is something that we try to recommend to our patients who can't make it to a dermatologist,” Dr. Singla said.

Dr. Singla reminded his audience that anxiety and depression are overrepresented in patients with IBD and that treating these mood disorders is important. “It improves compliance; it improves your doctor-patient relationship,” he said.

Tobacco use in IBD, meanwhile, is associated with various poor outcomes, including worsening flares, arthropathy, immunosuppression, repeat surgeries, perianal complications, stenosing phenotype, and decreased response to infliximab, Dr. Singla noted.

“While I hope that we have sort of set aside the ‘maybe a couple of cigarettes a day helps ulcerative colitis,’ we recommend tobacco cessation to every patient we have with IBD,” he said. “I don't think that we are any longer saying ‘Oh, if you have [ulcerative colitis] you can continue to smoke, but if you have Crohn's disease you have to stop.’ We recommend stopping to everybody.”