2. Health Maintenance in the IBD Patient John D Betteridge

3. Health Maintenance in IBD What We Will Cover Vaccines –Live vs. Inactivated Other than Vaccines –Dysplasia/Cancer Colon, Cervical, Skin –Bone density –Smoking Cessation –Depression Screening What We Won’t Related Diseases/ EIM’s –VTE, Arthritis, Autoimmune Medication Side Effects –Direct, Autoimmune Micronutrients –Iron, B12, Vitamin D

4. 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?

5. 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

6. 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

8. 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

9. 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

10. 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

11. Vaccine Efficacy

12. Vaccines Safety IBD clinical score activityCD (N390)UC (N158)IC (N6) HBI at baseline, median (IQR)1 (0;3)na PMS at baseline, median (IQR)na1(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 (0.81 (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

13. 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)www.CDC.gov Varicella, MMR, HZV

14. 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

15. 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

16. Vaccines Summary Prepare to Give Tdap Influenza Pneumococcus Hepatitis A, B Meningococcus Give 4-12 weeks before Tx MMR Varicella Zoster Earlier the Better!

17. 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

18. 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

19. Cervical Cancer Kane et al. Amer J Gastro 2008 Mayo: IBD and Immunosuppressed IBD women have more cervical dysplasia

20. Cervical Cancer St Marks: IBD women with no more Risk for Cervical Dysplasia than Control Lees et al. Inflamm Bowel Dis 2010

21. 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

22. 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

23. 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

24. 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 Eaden etal. Gut 2001; 43:526-535 Söderlund S et al. Gastroenterology 2009

25. 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

26. Colon Cancer Ulman T et al. Gastroenterology 2013

27. 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

28. 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

29. Depression Simple screening: –In past month, have you felt down depressed or hopeless? –In past month, have you felt little interest in doing things?

30. 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.

31. QUESTION

32. Questions?