Promoting Good Health in Patients With Inflammatory Bowel Disease

Are you doing enough to enhance and protect good health status for your patients with inflammatory bowel disease (IBD)? Maybe not, reported Francis A. Farraye, MD, MSc, Clinical Director of the section of gastroenterology at Boston Medical Center and Professor of Medicine at Boston University School of Medicine.

Patients with ulcerative colitis and Crohn disease typically do not receive preventive services at the same rate as general medical patients, Farraye told attendees of the American College of Gastroenterology Annual Scientific Meeting and Postgraduate Course. Vaccination-or lack thereof-is especially a problem in this patient population, since the immunomodulators and biologics used as part of treatment put patients at risk for infections and worse outcomes with infections. In fact, he added, there have been reports of fatal infections in patients with IBD-infections that could have been prevented.

How bad is it? An important study of 169 patients with IBD, 145 of whom were immunosuppressed, found that only 28% of the patients had received flu shots, and only 9% received pneumonia vaccine.¹ Furthermore, about half (49%) of patients reported they did not get flu shots because of lack of awareness. Another study found similar results, noting only 12% of 2076 patients received hepatitis B vaccinations.

Farraye noted these low rates were partly the result of confusion and reluctance among clinicians. This was evident in a study of gastroenterologists about vaccinating their patients. The study found that 20% to 30% would erroneously give a live vaccine to an immunosuppressed patient, while an equal number would withhold vaccines from non-immunosuppressed patients.² Similarly, in a study of primary care physicians, only 37% said they felt comfortable providing general medical care to patients with IBD and only 30% felt comfortable coordinating vaccinations for these patients.³ And almost half of gastroenterologists do not even inquire about their patients’ vaccination status.⁴ So it’s no wonder these patients are not receiving necessary care, Farraye said.

Regardless of immunosuppression status, there are a number of vaccinations that are safe and important for patients with IBD, Farraye noted. Patients should receive tDap, HPV, influenza (injectable vaccination is safe for all patients, but intranasal vaccine can only be used in patients who are not immunosuppressed, since a live virus is used), pneumonia, hepatitis A, hepatitis B, HPV, chickenpox, and meningococcal vaccine if they will be at risk (eg, because of military involvement, college, travel). Patients traveling outside the country who need special vaccines should be referred to travel clinics.

Varicella and zoster vaccinations can be given in non-immunosuppressed patients, but these vaccines are contraindicated in patients who are immunosuppressed or in patients for whom treatment with biologics will be initiated within 3 months. Family members of immunosuppressed patients can and should receive varicella vaccination. However, Farraye added, if a rash develops at the injection site, family members should avoid contact with the patient. The zoster vaccine is considered safe for patients receiving low-dose immunomodulators, as per the CDC. A retrospective study in patients taking biologic agents was recently published, Farraye noted.⁵ Not only did the researchers find that the vaccination was safe in immunosuppressed patients, but they also found that it had protective effects. However, Farraye cautioned that more studies are needed, and he said he would not recommend doing so for patients at this time. Again, family members can and should receive zoster vaccination.

Patients with IBD are also at increased risk for some cancers, so physicians should be diligent about talking with patients and ensuring necessary screening, Farraye added. Women with IBD have increased an prevalence of abnormal Pap screens because of their use of immunomodulators. Thus, annual Pap testing is important. Similarly, immunosuppressed patients appear to have an increased risk of skin cancer. In a study of thiopurines, the researchers found as much as a 6.75 increased risk for these patients.⁶ Primary care physicians should remind patients about the importance of sun protection and the need for an annual dermatologic evaluation.

Farraye noted the importance of monitoring patient’s bone health: patients with IBD are at increased risk for osteoporosis, osteopenia, and fractures. To combat these risks, make sure your patient is taking vitamin D supplements, selectively order bone density scans, and minimize corticosteroid use, he said.

Another wellness issue that should be addressed is smoking cessation, Farraye said. In patients with IBD, especially Crohn disease, smoking significantly worsens the course of illness. It leads to increased need for stronger therapies, such as corticosteroids and immunomodulators, and increased rates of relapse. Research shows a dose-response relationship with disease severity and smoking; so even if you can get your patients to cut down, they will see some benefits.

Research also has shown ophthalmologic issues associated with this patient population. Farraye said that ocular problems develop in about 10% of patients with IBD. Encourage your patients to see their eye doctor regularly for early detection.

Finally, patients with IBD are at increased risk for depression; approximately 15% to 35% of patients are affected. Farraye said these 2 simple questions will help alert the clinician to potential problems: Have you felt down, depressed, or hopeless? Do you feel less interested in or get less pleasure from doing things? Patients who exhibit signs of depression should be referred for treatment.

References
1. Melmed GY, Ippoliti AF, Papadakis KA, et al. Patients with inflammatory bowel disease are at risk for vaccine-preventable illnesses. Am J Gastroenterol. 2006;101:1834-1840.
http://www.ncbi.nlm.nih.gov/pubmed/16817843
2. Wasan SK, Coukos JA, Farraye FA. Vaccinating the inflammatory bowel disease patient: deficiencies in gastroenterologists knowledge. Inflamm Bowel Dis. 2011;17:2536-2540.
3. Selby L, Hoellein A, Wilson JF. Are primary care providers uncomfortable providing routine preventive care for inflammatory bowel disease patients? Dig Dis Sci. 2011;56:819-824.
4. Yeung JH, Goodman KJ, Fedorak RN. Inadequate knowledge of immunization guidelines: a missed opportunity for preventing infection in immunocompromised IBD patients. Inflamm Bowel Dis. 2012;18:34-40.
5. Zhang J, Xie F, Delzell E, et al. Association between vaccination for herpes zoster and risk of herpes zoster infection among older patients with selected immune-mediated diseases. JAMA. 2012;308:43-49.
6. Long MD, Herfarth HH, Pipkin CA, et al. Increased risk for non-melanoma skin cancer in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2010;8:268-274.

Further Reading
Moscandrew M, Mahadevan U, Kane S. General health maintenance in IBD. Inflamm Bowel Dis. 2009;15:1399-1409. http://www.ncbi.nlm.nih.gov/pubmed/19591135

Resources
Immunization Action Coalition. Ask the Experts. www.immunize.org/askexperts.