Aug. 19, 2022
Preventive care is a vital part of the management required for patients with inflammatory bowel disease (IBD), especially for individuals who receive certain immunosuppressive medications. This care often includes vaccination for vaccine-preventable diseases, screening for malignancies, mood disorders and osteoporosis, and encouraging smoking cessation.
In this Q&A, Jana G. Al Hashash, M.D., M.S., and Francis (Frank) A. Farraye, M.D., M.S., discuss approaches to vaccination, cancer screening and mental health screening for patients with IBD. Drs. Al Hashash and Farraye are gastroenterologists at Mayo Clinic's campus in Florida and co-authors of two review articles on this topic. Those review articles were published in Gastroenterology Clinics of North America in 2022 and in Current Treatment Options in Gastroenterology in 2021.
What do we know about rates of preventive care among patients with IBD when compared with the general population?
Rates of preventive care are lower among subsets of patients with IBD compared with the general population. One factor contributing to these lower rates is a lack of knowledge about current vaccination guidelines among primary care physicians and gastroenterologists who care for patients with IBD. Survey results have shown that physicians are uncomfortable recommending vaccinations to immunosuppressed patients and that their recommendations are sometimes inconsistent with the most current vaccination guidelines for patients with IBD. Thus, physician and patient education on preventive care recommendations is extremely important.
What must health care providers be aware of to optimize patient safety when considering vaccination for patients with IBD?
There are a variety of issues to consider. We know that certain immunosuppressive therapies affect patients' susceptibility to vaccine-preventable diseases and increase their risk of developing more-severe illness or complications. So, knowing what vaccines to give, the best time to vaccinate and the contraindications for certain vaccines is imperative.
Live vaccines, such as the varicella vaccine, the measles, mumps and rubella (MMR) vaccine, and the live influenza vaccine, are typically contraindicated in patients who are immunosuppressed. There are some exceptions to this rule that can be considered, but such decisions should be individualized and performed cautiously with multidisciplinary guidance. If deemed necessary, it is preferable to administer live vaccines four weeks before starting immunosuppressive therapy.
Non-live vaccines are safe and can be administered to all patients with IBD, even in individuals who are immunosuppressed. The list of currently recommended vaccines includes the following: inactivated influenza vaccine; pneumococcal conjugate vaccine (PCV-13, 15 and 20) and pneumococcal polysaccharide vaccine (PPSV23); tetanus, diphtheria and pertussis (Tdap) vaccine; meningococcus vaccine; hepatitis A and hepatitis B vaccines; human papillomavirus (HPV) vaccine; the inactivated recombinant herpes zoster vaccine (Shingrix); and the coronavirus disease 2019 (COVID-19) vaccine. Both articles that we published provide detailed information about the dosing schedule and special considerations for these vaccinations.
It is also important to understand that several immunosuppressive treatments may blunt the immune response to vaccines and subsequently decrease their efficacy. For example, patients who are receiving combination therapy with anti-TNF agents and an immunosuppressive drug have a blunted response to the pneumococcal vaccine and diminished immune persistence.
What misconceptions about vaccinations in patients with IBD would you like to refute?
The claim that vaccinations can trigger flare-ups of known IBD. There is no convincing research data supporting this claim.
What should physicians understand about cancer screening and surveillance in patients with IBD?
Patients diagnosed with IBD and those receiving certain treatments for IBD have an elevated risk of multiple cancers, including colon cancer, cervical cancer and skin cancer. The risk of melanoma and nonmelanoma skin cancers, for example, is higher in patients with IBD than in the general population. Use of immunosuppressants further increases this risk, and treatment with thiopurines elevates the risk of nonmelanoma skin cancers even further. Even after discontinuing thiopurines, this risk of skin cancer remains higher than the skin cancer risk in patients who have not received a thiopurine.
Patients with IBD require a more robust screening and surveillance schedule than what is typically recommended for the general population. Our articles explain the factors that contribute to these elevated risks, and we outline the schedule for screening and surveillance tests that are appropriate for patients with IBD.
What forms of mental illness affect patients with IBD and how should health care providers approach mental health screening in this patient population?
Similar to patients with other chronic illnesses, patients with IBD have been shown to have high rates of anxiety, depression and fatigue when compared with the general population. These conditions often remain underrecognized in these patients and can lead to significant morbidity. Because research suggests that depressive severity among these patients is associated with suicidal ideation, administering screening questionnaires for depression and anxiety, and providing follow-up care for patients who have high scores, is recommended. Identifying and addressing these mental health issues early can help avoid progression and improve patient outcomes.
For more information
Hashash JG et al. Health care maintenance in patients with Crohn's disease. Gastroenterology Clinics of North America. 2022;51:441.
Hashash JG, et al. Health maintenance for adult patients with inflammatory bowel disease. Current Treatment Options in Gastroenterology. 2021;19:583.
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