[00:30]
Hello, I’m Dr. Shubha Bhat and welcome to IBDIQ, part of The IBD Project by Takeda, where we’re coming together to help enhance expertise in IBD care—right from the start.
Thank you for joining me in this discussion of health maintenance and preventative care in inflammatory bowel disease, or IBD. During this presentation, we will discuss current recommendations in health maintenance and preventative care, as well as how to employ effective approaches to help improve patient adherence to current recommendations.
Patients with inflammatory bowel disease are at a higher risk of developing vaccine-preventable infections and other complications due to a dysregulated immune system caused by the disease or treatment with immunosuppressive therapies.1
With appropriate preventative care, such as vaccinations, most of these negative outcomes can be prevented.2 To further drive home the impact of health maintenance and preventative care, the Centers for Disease Control, or CDC, estimates that 6 million flu-related illnesses, 2.9 million flu-related health-care visits, 65,000 flu-related hospitalizations, and 3,700 flu-related deaths were prevented by flu vaccination in the general population during the flu season of 2022 to 2023.3
[01:50]
Despite the benefits seen with health maintenance and preventative care, among patients with IBD, adherence to these recommendations remains suboptimal.1,2
A questionnaire-based study at the Cedars-Sinai Inflammatory Bowel Disease Center surveying 169 patients with IBD reported that among 146 patients with exposure to immunosuppressive medications, only 28%, or 41 out of 146 patients, received the flu vaccine regularly and only 9%, or 13 out of 146 patients, received a pneumococcal vaccine.4 Patients identified reasons for suboptimal vaccination rates such as lack of awareness and fear of side effects.4
An additional barrier to optimal adherence rates identified is confusion about vaccination responsibilities among gastroenterologists and primary care providers, or PCPs.1
Typically, PCPs assume the responsibility for preventative care, however, patients with IBD often consider their gastroenterologist to be their PCP due to the frequency of interactions and follow-ups.1,5
[03:02]
Further complicating this situation, gastroenterologists may lack knowledge given an immunocompromised population, as evidenced by a 2009 questionnaire-based survey study of 108 members of the American College of Gastroenterology.6 The survey reported that 20%-30% of gastroenterologists would incorrectly recommend live vaccines to immunocompromised patients.6
Primary care providers in a 2021 cross-sectional study have expressed lower comfort levels with vaccinations in immunocompromised patients, preferring that the gastroenterologists assume the responsibility for this population.5
Ultimately, confusion among providers about who is responsible for vaccinations leaves patients with a lack of recommended vaccines and preventative care.1
For the remainder of this presentation, we will focus on the various requirements and needs for health maintenance and preventative care for patients with IBD. These include vaccinations, cancer screening (including colorectal cancer screening for all IBD patients, and cervical and skin cancer screening for those patients being treated with immunosuppressants), bone health, nutrition, mental health assessment, and smoking cessation.7-11
[04:21]
Let’s take a moment to review the risks of serious and opportunistic infections associated with immunosuppression.7
This graphic, taken from a nationwide population-based study based on the French National Health Insurance database included approximately 191,000 patients with IBD.12 Overall, 8,561 serious infections and 674 opportunistic infections occurred. The greatest risk for opportunistic infection was shown to be associated with combination therapy, compared with anti-tumor necrosis factor, or anti-TNF, monotherapy use.
The most common serious infections affected the lung in 24.2% of patients, the gastrointestinal tract in 22.5% of patients, and the skin in 17.2% of patients.12 Additionally, patients older than 65 years of age were also more likely than younger patients to have an increased risk of serious and opportunistic infections on treatment.
As seen in this study, there is a risk of infections in patients with IBD on immunomodulating therapies, highlighting the importance of mitigation approaches, such as vaccinations.7
[05:38]
While vaccinations are an important part of preventative care, many patients express hesitancy related to vaccines.13 Now, let’s talk about vaccinations. In my experience, one of the common reasons for vaccine hesitancy among patients is the concern that vaccines may cause flares or disease worsening.
This concern was refuted in a recent systematic review and meta-analysis of 13 studies involving 2,116 patients.13 The studies included several vaccines, including influenza, pneumococcal, recombinant herpes zoster, and hepatitis B. The majority of adverse events following vaccination were local, with a reported pooled incidence of 24%, or mildly systemic, with a reported pooled incidence of 16%. A pooled incidence of 2% was found for IBD flare post-vaccination.
We can conclude from this study that vaccination-related adverse effects are mainly local or mildly systemic and do not differ significantly from the reported rates observed within the general population.13
Vaccine safety should be continually discussed and reinforced with patients who may have concerns.13
[06:55]
There are several guidelines available that may help guide vaccination practices for patients with IBD. The most recent publications are from 2013 and 2017.14,15
Personally, the CDC website is my go-to guide for current recommendations. However, in general, it is recommended to follow standard, age-appropriate immunization schedules, with certain exceptions which we will review in the upcoming discussion.15
So let's explore the significance of the influenza vaccine.
The influenza vaccine is a crucial vaccine recommended for patients with IBD.16 A retrospective cohort study analyzing the MarketScan Health Claims Database of approximately 140,000 patients with IBD from 2008 to 2011 found the incidence of influenza to be higher in patients with IBD compared to those without IBD.8 Interestingly, there was an age-related trend observed, with the younger population experiencing the highest rates of influenza.8
[08:00]
Patients with IBD should obtain one dose of inactivated influenza vaccine annually.7,18 Patients on anti-tumor necrosis factor, or anti-TNF monotherapy, should specifically receive a high-dose influenza vaccine, due to the potential immune response attenuation and higher post immunization antibody levels observed with high dose influenza vaccine.19 Additionally, patients 65 years or older should receive the high-dose influenza vaccine as well.18,19
Several formulations of the influenza vaccine are available. As with any other vaccinations, it is important to note that patients considered immunocompromised or on immunomodulating therapies should avoid receiving live vaccines, which for influenza comes in an intranasal formulation.14,18
[08:53]
In addition to the influenza vaccine, pneumococcal pneumonia vaccine is also important for patients with IBD.7 This is demonstrated by the results of a retrospective cohort study of approximately 107,000 patients with Crohn’s disease, or CD, or ulcerative colitis, or UC, compared to more than 430,000 patients without IBD, which analyzed claims in the LifeLink Health Plan Claims Database in the United States from 1997 through 2009.20 They found the annual incidence of pneumonia to be much higher in the IBD population compared to the non-IBD population.20
Previously, only one pneumococcal vaccine was available.21,22 Now, it is being replaced by two additional pneumococcal conjugate vaccines.21,22 Due to the addition of these two vaccines, dosing recommendations are trickier as now we must determine what pneumococcal vaccine patients have received in the past, may need now, and when to administer that dose.21
All patients above 65 years of age should receive the pneumococcal pneumonia vaccine.21 Patients between the ages of 5 to 64 years considered at risk for pneumococcal disease are eligible to receive the vaccine.
[10:13]
Now, let’s explore the importance of herpes zoster vaccination for patients with IBD.
Patients with IBD should highly consider receiving the herpes zoster vaccine as they are at a higher risk for herpes zoster, also known as shingles.23
Prior to 2021, the herpes zoster vaccine was only available to individuals 50 years and older, but CDC guidelines have been recently revised to recommend two doses of the shingles vaccine in adults 19 years or older who are immunodeficient or immunosuppressed due to disease or therapy.24 Currently, the live formulation of this vaccine is no longer available in the United States and those who have received the live formulation are still encouraged to receive vaccination with the inactivate formulation based on its efficacy.
Clinical trials have identified that certain medications, such as Janus kinase inhibitors, or JAK inhibitors, and sphingosine-1-phosphate receptor, or S1PR modulators, are associated with an increased signal and rate of herpes zoster reactivation.25,26 Vaccinations in these treatment cohorts are strongly recommended prior to treatment initiation to provide additional safety benefits.23,27
It is to be noted that even with the new guideline updates, not all insurances are readily covering the shingles vaccine in the immunocompromised population; additional steps, such as prior authorization, may be required to obtain vaccination coverage.23,24
[11:51]
Let’s now shift our focus to the hepatitis B vaccine. It has been hypothesized that this vaccine may be less effective in patients with IBD compared to individuals without IBD.28
In a 2021 systematic review and meta-analysis of 2,375 patients from 14 studies, it was reported that patients with IBD had a statistically inferior immune response to the hepatitis B vaccine compared to patients without IBD.28
The risk of hepatitis B reactivation is high in patients with IBD on certain classes of therapy.29 However, hepatitis B vaccination uptake in the IBD population remains low.30 Moreover, of the patients with IBD who receive vaccination, seroconversion rates indicating immunity post-vaccination remains lower when compared to the general population.28 According to the same meta-analysis I mentioned a moment ago, the pooled proportion of adequate immune response with hepatitis B vaccination among patients with IBD was only 64%.28
There are several hepatitis B vaccine formulations available, including one that is a two-dose series, whereas others are three doses.29 After completing the vaccination series, surface antibody levels can be rechecked 4 to 8 weeks later to confirm immunity against hepatitis B.7,29
In the IBD population, you may need to vaccinate a patient multiple times since they are either not able to mount immunity or lose immunity over time.29,31
[13:35]
Next on our list of vaccinations for patients with IBD is vaccination against respiratory syncytial virus, or RSV.
RSV is a respiratory virus with significant severity which can result in complications, such as lower respiratory disease, hospitalization, and death.32 A recently presented cohort study at the American College of Gastroenterology Annual Scientific Meeting in 2023 found that adult patients with IBD have a two-fold greater risk of developing RSV compared to the non-IBD population.33 Patients with IBD and additional comorbidities, including diabetes, chronic lung disease, cardiovascular disease, and chronic kidney disease, were at a significantly increased risk of RSV-associated hospitalizations.32
Two RSV vaccines were approved in 2023 and are now available for use in patients, specifically those above 60 years old or pregnant.34,35 No recommendations exist currently for the immunocompromised IBD population and further studies are required to assess the vaccine’s safety and efficacy.32
[14:52]
Shown here are the current considerations for vaccinations within the IBD population as of 2024. Other vaccines for preventative care for adults not discussed in this presentation include hepatitis A, human papillomavirus or HPV, tetanus, and COVID-19.7,32
Please remember to check the CDC website for evolving guidance and information on vaccine recommendations for your patients.
Vaccine administration is generally recommended at least two weeks prior to immunosuppressive treatment initiation.36 This allows a patient to have some protection and minimizes reduction or blunting of vaccine effects by treatment.7,37,38
It is critical to remember that, in most cases, live vaccines should be avoided in immunocompromised patients as immune response may be blunted and result in active infection. Some examples of live vaccines include measles mumps rubella, varicella, nasal formulation of the influenza vaccine, and some travel-based vaccines such as yellow fever and typhoid.36
Special populations, such as pregnancy and lactation, may have different vaccine recommendations. Please refer to the CDC website for recommendations relating to special populations.29
[16:20]
Highlighting the previous discussion of whether gastroenterologists or PCPs should take ownership of health maintenance and preventative care, I believe both teams should be accountable. Given time constraints and other issues like cost and storage space for vaccines, it may be beneficial for gastroenterologists to work closely with PCPs to provide healthcare maintenance.7
Outlined here is a guide on how a vaccination program can be implemented in outpatient gastroenterology practices.39
A vaccine champion should be identified as the one willing to take responsibility for learning about vaccines and current recommendations, and providing education to staff.39
In an ideal case scenario, the practice has the capability to provide the vaccine and should follow the steps outlined on the screen here to administer the vaccine to patients.39
If the practice does not have the capability to provide the vaccine, an effort should be made to direct patients to their local pharmacy to receive these vaccines.39
[17:28]
We will now be focusing on cancer screening for a patient with IBD.
A significant risk factor for colon cancer is uncontrolled inflammation and disease.40,41 Colonoscopies remain the best practice for screening.42
All patients with IBD with at least 8 years of disease duration and colonic involvement (excluding those with ulcerative proctitis, ulcerative proctosigmoiditis, and those with Crohn’s disease involving less than one-third of the colon) are at increased risk of colorectal cancer and should initiate colorectal cancer screening every 1 to 3 years.9
Follow-up surveillance is recommended within 1 to 5 years and is dependent on the patient’s colonoscopy findings, family history, and other comorbidities, such as primary sclerosing cholangitis.42 Shown here is an overview of the recommended timeline for screening re-evaluation depending on the individual risk factors present.
[18:31]
Cervical cancer is another important malignancy to screen for in women with IBD as there is an increased risk of cervical dysplasia and cancer observed in patients on immunosuppressive medications.10 Of concern, a survey study of PCPs, gynecologists, and gastroenterologists affiliated with Saint Louis University School of Medicine in Missouri from April 2018 to January 2019 found a significant knowledge gap among gastroenterologists; 63% were unfamiliar with cervical cancer screening recommendations.43
Screening recommendations for patients with IBD receiving immunosuppressive medication have been extrapolated from the human immunodeficiency virus, or HIV population, as they both share an immunocompromised status.43 It is recommended to begin screening at 21 years of age, conducting cervical cytology with varying frequency depending on the age, and for those over 65 years of age, consider continuing cervical cancer screening.10,43,44
[19:42]
Skin cancer monitoring is also a preventative care recommendation for patients with IBD due to observed cases of melanoma and non-melanoma skin cancer in patients on immunosuppressive therapy.10
Studies have found an association of skin cancer with medications, such as thiopurines and anti-TNF therapy.10 Therapy with thiopurines showed more cases of non-melanoma skin cancer, whereas anti-TNF therapy showed more cases of melanoma.
Patients with IBD who are receiving immunosuppressant therapy should have an annual skin exam, use preventative measures such as sunscreen application with a sun protection factor, or SPF, greater than 30, and avoid the sun during peak hours.10,45
[20:30]
We have covered vaccines and cancer screening, now I would like to review additional preventative care recommendations for a patient with IBD, including bone health, nutrition care pathway, mental health, and smoking.
A common comorbidity seen in patients with IBD is osteoporosis, which, according to published literature, carries a risk of 15% to 40% depending on the study population, location, and design.10 Risk factors for osteoporosis include age, cumulative corticosteroid exposure greater than 3 months, tobacco use, low body mass index in settings of dietary restrictions or malnutrition, and hypogonadism.10
In the case that risk factors are present, the current consensus is to conduct a central DEXA scan including the hip and spine. This test should be repeated in 5 years if the initial results are normal.10
There are some recommendations that help reduce further bone density loss, which include vitamin D level monitoring with supplementation if deficient and consumption of adequate calcium via diet and/or supplementation.10, 46-48 Regular physical activity is also a successful preventative care approach.48 Smoking cessation and limiting alcohol intake is also recommended to help slow down bone density loss.10,48
[21:55]
Nutritional deficiencies are common in patients with IBD, especially in the setting of complicated disease.8 It is important to address as patients can experience associated consequences such as hair loss and anemia.
A nutrition care pathway by the Crohn’s and Colitis Foundation has been developed to assist providers in identifying, assessing, and treating patients at moderate or high risk of nutritional deficiencies.11
Patients with IBD, at baseline, should have labs including iron, vitamin B, vitamin D, folate, and zinc monitored.11 Patients who are at high risk should have a dietitian involved for further management.
IBD is associated with many complications, including development of depression and anxiety, which can potentially cause a reduced quality of life for many patients.49 Mental health screening is another element of preventative care.10
A systematic review has identified rates of depression and anxiety in patients with IBD to be 21% and 19%.10,50 Depression in patients with IBD has been associated with an increased risk of 90-day re-admission, surgery, and unnecessary computed tomography scans and colonoscopies.10
The current recommendations for mental health screening include a depression and anxiety screen with the Patient Health Questionnaire, or PHQ9, and General Anxiety Disorder, or GAD7, questionnaire at baseline and annually.10 If a patient has a positive screen for depression or anxiety, they should be referred for counseling or therapy.
[23:37]
Smoking cessation is another important element in preventative care in patients with IBD.7,10 Smoking increases the risk of extraintestinal manifestations, complications, hospitalizations, surgery, and overall poor response to treatment in Crohn’s disease.10
Despite the negative implications of smoking, a questionnaire-based study from 2018 surveyed gastroenterologists from the distribution lists of the Crohn’s & Colitis Foundation of America and the Gastroenterology Training Directors Listserve and found that only about 60% of gastroenterologists counseled patients on the importance and benefits of smoking cessation more than 75% of time.10,51
The current recommendation is to assess smoking status at baseline and refer smokers to smoking cessation services.10 An example of a service for smoking cessation is the National Network of Tobacco Cessation Quitlines.52
[24:39]
One key theme of today’s discussion is that patients with IBD can experience significant health maintenance and preventative care benefits through consistent interventions.
Improved adherence to health maintenance and preventative care recommendations can be achieved through these potential approaches:
Build a vaccine checklist and preset orders for associated referrals within the electronic health record.39,53
Assign a vaccine champion in clinic who will advocate for best practices and stay informed on current recommendations.39
Utilize team-based care to work closely with primary care clinicians, including defining who is responsible for vaccination and screenings, to ensure patients are receiving appropriate and up-to-date healthcare maintenance.7
Explore opportunities to provide immunization services in the clinic or pharmacy and collaborate with other disciplines.7,39
[25:39]
In summary, health maintenance and preventative care remain an important cornerstone in IBD management.7 Despite this, current adherence to preventative care is unfortunately suboptimal due to many barriers.7 This, however, provides a great opportunity for gastroenterologists and their teams to collaboratively assess patients’ needs in their practice.54
I hope you enjoyed learning about immunizations, cancer screening, bone health, nutrition, mental health, and smoking cessation evaluations; all are important for the overall health of the patient.
Thank you for your interest and for spending some time with IBDIQ today to help adapt to the evolving care needs of all patients with IBD.
