A Preventive Care Roadmap for IBD

Hello. I’m Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School and Old Dominion University in Norfolk, Virginia. 

I wanted to highlight a valuable new resource published in the July issue of the American Journal of Gastroenterology. It’s an update on the preventive care of patients with inflammatory bowel disease (IBD). Kudos to the American College of Gastroenterology for assembling this panel of IBD experts, led by Dr Francis Farraye, to update the prior guidelines. 

This is essential reading for primary care physicians, gastrointestinal (GI) specialists, or anyone caring for patients with IBD. The guideline also includes a wonderful visual summary that can be used as a wall chart in your office, intake area, or clinical exam rooms, which I think you’ll find invaluable. 

I’ll touch on a few foundational points around vaccines, general screening and risk considerations, and then highlight the individual vaccine recommendations. 

General Vaccine Recommendations

The first foundational concept is that inactivated vaccines should be used for any patients with IBD who are on immune-modifying therapy or immunosuppressants. These vaccines often require multiple doses, such as the influenza vaccine, which should be administered annually. 

Second, vaccination history is key and should be part of your baseline intake for any patient newly diagnosed with IBD. This is important not only for the patient but also for their household contacts. 

Third, co-administration is both easy to perform and effective. For example, if a patient comes in for their annual influenza shot and hasn’t yet received their updated polyvalent pneumococcal vaccine, the two can be co-administered. Evidence shows compliance improves when these vaccines are administered in the GI office, although this may not always be possible. 

Risks and Screening Concerns

Patients with IBD have several notable baseline risks that must be considered. 

Infection risk increases with IBD, and we see mucosal disruptions rising when we initiate therapies, such as immunosuppressant steroids and biologics. Dysplasia related to either intestinal or colon disease is not discussed in this guideline, but they do delve into other key areas that really are deserving of our focus. 

Since cervical cancer is associated with human papillomavirus (HPV), the guidelines recommend that women who are 9-26 years of age should receive the HPV vaccine. For women with IBD on immune-modifying therapies, cytologic assessment for HPV should be initiated within a year of the beginning of sexual activity and if younger than 30 years. It should be repeated yearly for 3 years and then every 3 years thereafter, typically under the care of an obstetrician/gynecologist.

Skin cancer is another important concern. Melanoma is increased by approximately 35%-40% in this population, independent of the use of biologics or immunosuppressants. Although melanomas account for only about 1% of skin cancer diagnoses (the majority are squamous or basal cell carcinomas), they cause a disproportionately high number of deaths. 

Non-melanoma skin cancers are not related primarily to IBD but are associated with thiopurine use. This risk can persist even years after thiopurine discontinuation. 

All our patients with IBD should be counseled on skin cancer prevention. This should include yearly examinations by a dermatologist, including a total body inspection. Recommend the use of SPF clothing, including hats, and sunscreen, as well as modulating sun exposure. 

Patients with IBD may be at an increased risk for osteoporosis or osteopenia. The cytokines that drive IBD (ie, tumor necrosis factor alpha, IL-6, IL-1) increase osteoclastic activity and impede osteoblastic maturation. Patients also may be at an increased risk for vitamin D deficiency. Baseline screening for osteopenia is recommended, and then sequentially as the risk increases over time.

Screening for anxiety and depression should be incorporated. This is something that’s new to these guidelines, as research has shown it is more prevalent in those with IBD than the average population in the United States. Validated intake tools for identifying anxiety and depression are available. 

Sexual history is something not mentioned by this guideline but is worth our attention. Sexual disruption is significantly increased in this population, and making relevant referrals may be valuable. 

And of course, smoking cessation should be encouraged, particularly among patients with Crohn’s disease.

Individual Vaccines

The influenza vaccine is recommended for all patients with IBD, although the intranasal form should be avoided in patients who are on biologics or immunosuppressants. However, even if they’re on any of those immune-modulation therapies, they should receive the influenza vaccine annually.

It is also recommended that they be vaccinated against COVID-19, per the current recommendations from the US Centers for Disease Control and Prevention. 

Pneumococcal vaccination is recommended for all patients older than age 50 and also for those 14-49 years of age who are on any type of immunologic therapy, as pulmonary infections tend to be more severe in patients with IBD.

While respiratory syncytial virus vaccination is recommended for patients with IBD if they’re older than 75 years or are receiving immune therapy, this guideline basically says all eligible patients with IBD should receive it.

Herpes zoster vaccination is recommended for all patients 19 years or older who are on immunomodulators and for all patients older than 50 years of age with IBD. Because this is an inactive vaccine, patients who are immunocompromised do not need to wait 6 months for their second vaccine. The interval can now be shortened to 1-2 months after the first dose. 

Adults with IBD should be evaluated for varicella infection (chickenpox). Immune testing is not recommended due to the high false-negative rates. If they have a well-documented history of chickenpox, you can still prescribe the vaccine. You do not have to wait if they are on immunomodulators.

The guidelines recommend that children with in-utero exposure to biologic therapy be offered a live rotavirus vaccine within the first 8 months of delivery. Patients who are immunologically suppressed should avoid direct contact. All contacts should thoroughly wash their hands after changing the diapers of infants who received the vaccine. This is because shedding may occur for at least a month after the last dose.

Other standard vaccines, including hepatitis A, hepatitis B, and tetanus, are also recommended. 

All adults with IBD should receive Tdap vaccination. Pregnant women should receive Tdap between the 27th and 36th week of each pregnancy. This is because the passive maternal antibody produced by vaccination is important to the fetus, protecting against pertussis in the first 0-2 months of life. 

Optimized Care

These preventive care measures should become a standard part of your IBD assessment. They should be a part of your routine questions, not only for patients but also for their household contacts. 

Take advantage of the helpful wall chart included with your mailed copy of the American Journal of Gastroenterology. Put it up in your office, where it can serve as an invaluable resource.

Most importantly, review this guideline in detail. It’s critical reading that will allow you to take steps forward in optimizing the care of your patients with IBD. 

I’m Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

https://www.medscape.com/viewarticle/preventive-care-roadmap-ibd-2025a1000nkr