1. Health Maintenance for the IBD Patient: Why, By whom, what, when & how? Sharon Dudley-Brown, PhD, CRNP, FAAN Assistant Professor School of Medicine Johns Hopkins University sdudley2@jhmi.edu

2. Preventive Health Issues/ Health Maintenance Why and by whom? Vaccinations Tb screening Periodic lab testing Colonoscopies Tobacco cessation Osteoporosis screening/monitoring Other screening How?

3. Why? & By Whom? Younger IBD patients frequently don’t have a PCP PCPs rely on the specialist w/ complicated patients IBD patients receive fewer screening & preventive health services compared w/ non-IBD patients same age Selby et al, Inflamm Bowel Dis, 2008: 14: 253-8

4. Vaccinations For most IBD patients, recommendations for immunization don’t deviate from the general population –Influenza & pneumococcal pneumonia are the most common vaccine preventable illnesses in adults Exceptions –Early dosing Pneumococcal vaccine polyvalent Zoster –Live virus vaccines Sands et al, Inflamm Bowel Dis, 2004; 10: 677-92 Melmed, Inflamm Bowel Dis, 2009; 15:1410-6

5. Vaccinations Tetanus: on time, then q 10 yr boosters HPV: all females age 9-26 Influenza (attenuated): annually Pneumococcal: 1 dose age 19-26, then in 5 years Meningococcal: only for asplenia, first year college students, military, travelers Hep A: 2 doses or check titer and boost if - Hep B: 3 doses, check HBsAb, and boost if – ACIP; Ann Intern Med, 2009: 150:40-4 Melmed, Inflamm Bowel Dis, 2009; 15:1410-6

6. Live Vaccines* Bacille-Calmette-Guerin Influenza inhaled (LAIV) (parental attenuated) Measles, Mumps, rubella Typhoid (oral) (parental attenuated) Polio (oral) (parenteral attenuated) Vaccinia (smallpox) Varicella Yellow fever Zoster *Contraindicated for patients on biologics, steroids, ? Azathioprine, MTX ACIP; Ann Intern Med, 2009: 150:40-4 Melmed, Inflamm Bowel Dis, 2009; 15:1410-6

7. Zoster Vaccine Contraindicated: high dose steroids (> 20 mg/ day) for 2 or more weeks. Defer for 1 month after discontinuation Therapy w/ low dose MTX (<0.4 mg/kg/week), Azathioprine (<3.0 mg/kg/day) or 6-mp (<1.5 mg/kg/day) are not considered sufficiently immunosuppressive and are not contraindications for zoster Safety & efficacy unknown- anti-TNF agents –Defer for one month after discontinuation MMWR, May 15, 2008/57 (early release); 1-30

8. 24 y.o. F w/ CD, on IFX, and HPV positive asks you if she should have the HPV vaccine….Do you recommend vaccination? 1.No, HPV is contraindicated w/ IFX 2.No, too late, the HPV vaccine is ineffective 3.Yes, some protection is better than none

9. 28 y.o. F w/ UC on 6-MP doesn’t recall having chickenpox as child, nor vaccination. Which is appropriate? 1.Vaccinate now against varicella 2.Check VZV titer and vaccinate only if negative 3.Check VZV titer but don’t vaccinate even if negative

10. 21 y.o. F w/ CD on 6-MP wants to go to Brazil, endemic area for yellow fever. What do you tell her? 1.Get the vaccine before you go 2.The vaccine is contraindicated, so go to Brazil without the vaccine 3.Don’t go to Brazil

11. Tuberculosis Screening Before immunosuppressive therapy begins –PPD –Prior BCG- PPD positive x 10 years –QuantiFERON Gold How often? Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409

12. Periodic Lab Testing New patient –CBC, liver enzymes, BUN/creat, fasting glucose, lipid panel, vit B12, ferritin, folate, iron, Vit D-25-OH All patients –CRP, sed rate –Vit D 25-OH Medication dependent Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399- 409

13. Medication Dependent Lab Testing 5-ASA: annual creatinine Steroids: Vit D 25-OH, glucose, BMP AZA/6MP: TPMT prior, CBC, LFTs weekly x 4, monthly x 3, then q 3 months MTX: CBC, LFTs q 2 weeks x 2, then monthly x 3, then q 3 months Biologics: Hep A, B, C, CBC, liver enzymes periodically (q 3-6 months) Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399- 409

14. Colonoscopies Multiple roles –Extent & severity –Mucosal healing –Post op recurrence –CRC surveillance Surveillance for CRC begins 8-10 years after diagnosis for colonic disease –Those w/ PSC: immediate and annual surveillance Interval may be shorter than 1-2 years w/ family history, PSC or history of dysplasia Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409

15. Tobacco Cessation Negative effect on Crohn’s disease and its treatment –Reduce response to medication, increase risk of post-op recurrence, shorten duration of remission Smoking cessation is PRIMARY therapy for Crohn’s disease Consider buproprion- has anti-TNF properties Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409

16. Osteoporosis Screening/Monitoring DEXA is gold standard –Osteoporosis if T score < -2.5 Screening –Any steroid use > 3 months; post menopausal/ > age 50; personal history of low trauma fracture Lifestyle modifications –Smoking cessation, wt bearing exercise, adequate calcium & vit D Bisphosphonates & other meds –Refer to endocrinologist specializing in osteoporosis Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409

17. Other Screening Cancers –Cervix –Breast –Skin –Anal –Prostate Blood pressure Depression Ophthalmologic Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409

18. Other Health Maintenance Issues Contraception Use of NSAIDs Need for PCP/Medical Home

19. How is this implemented in practice? Issues –EMR –Availability & ordering –Assuring follow through –Documentation Who is responsible? –RN, APN, MD Measuring outcomes

20. Summary Preventive health issues are important –Vaccinations- collect vaccine history –Tb screening –Periodic lab testing –Colonoscopies –Tobacco cessation –Osteoporosis screening/monitoring –Other screening