ACG issues new guidelines for preventive care in IBD patients
A new clinical guideline released by the ACG highlights the importance of preventive care in patients with inflammatory bowel disease, and recommends co-management of health maintenance issues by gastroenterologists, primary care providers and other specialists.
To provide an outline of preventive care services required by IBD patients and how to best deliver them, Francis A. Farraye, MD, MSc, FACG, of the section of gastroenterology, Boston Medical Center, and professor of medicine at the Boston University School of Medicine, and colleagues reviewed relevant literature published up to 2016, and assessed the strength of their recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Francis A. Farraye
The resulting guideline includes recommendations on vaccinations, smoking cessation, and screening for cervical cancer, melanoma and non-melanoma skin cancer, osteoporosis, depression and anxiety.
Timely administration of vaccines is especially important in IBD patients because of the association between immunosuppressive therapies and an increased risk for infections, many of which can be prevented by vaccines, Farraye and colleagues wrote.
“Combinations of an immunomodulator and biologic agent are being used more frequently and earlier in subsets of patients with ulcerative colitis and Crohn's disease who present with or have signs and symptoms of an aggressive course,” Farraye told Healio Gastroenterology. “Patients on steroids, immunomodulators or biologics are at an increased risk of developing infectious complications including infections with opportunistic organisms. Vaccinations may lower the risk of infections with some of these organisms but vaccination rates in IBD patients remain too low.”
The guideline authors recommended that age-appropriate vaccination schedules should generally be adhered to, except for some IBD patients receiving or beginning treatment with immunosuppressants, who may delay some vaccinations.
“Ideally vaccinations should be administered prior to starting immunosuppressive therapy, as vaccine efficacy is higher in the non-immunosuppressed IBD patient,” Farraye noted.
Additional recommendations include that all adults with IBD, whether immunosuppressed or not, should receive non-live vaccines in accordance with national guidelines, “including trivalent inactivated influenza vaccine, pneumococcal vaccination (PCV13 and PPSV23), hepatitis A, hepatitis B, Haemophilus influenza B, human papilloma virus (HBV), tetanus, and pertussis.” On the other hand, certain live vaccines, such as the herpes zoster vaccine, are recommended for patients on “low-level” immunosuppression.
“The treating gastroenterologist should partner with the PCP to be certain that vaccinations are administered in a timely fashion,” Farraye said.
Other health maintenance issues
Beyond vaccinations, Farraye and colleagues emphasized the importance of smoking cessation in patients with IBD, as well as screening for depression, and certain non-gastrointestinal cancers and osteoporosis in patients with an increased risk for these conditions due to their IBD diagnosis or the medications used to treat it.
“Screening for osteoporosis, cervical cancer, melanoma and nonmelanoma skin cancer are needed in subsets of IBD patients and will require referral to PCP, dermatology, endocrinology and gynecology on a case by case basis,” Farraye said.
The guideline authors’ cancer screening recommendations include that women with IBD on immunosuppressants should be screened for cervical cancer annually, that all IBD patients should be screened for melanoma regardless of whether they are on biologic therapy or not, and that IBD patients should be screened for non-melanoma squamous cell cancer while using thiopurines, especially if they are over the age of 50.
In regards to screening for osteoporosis, patients with conventional risk factors for abnormal bone mineral density — including steroid treatment, systemic effects of chronic inflammation, calcium and vitamin D deficiencies, and malnutrition — should be screened at the time of diagnosis and periodically afterward, the authors wrote.
In addition, they also recommended that patients with IBD should be screened for depression and anxiety, as identifying and addressing these issues may be important for managing IBD and improving outcomes. Anxiety affected 19% of IBD patients compared with 9.6% of the general population, while depression affected 21.2% of IBD patients vs. 13.4% of controls without IBD, according to a systematic review cited in the guideline.
“The treating gastroenterologist should try to identify their patients with anxiety and/or depression and refer to the PCP or behavioral health for treatment,” Farraye said.
Finally, the Farraye and colleagues highlighted data showing smoking is associated with the development and progression of Crohn’s disease, as well as poorer medical and surgical outcomes.
“All IBD patients should be encouraged to stop smoking,” Farraye said.
Because gastroenterologists are often the only clinician seen by IBD patients, it is essential for them to take a proactive role in their patients’ health care needs, the authors concluded. To effectively co-manage the health maintenance issues of IBD patients with their PCPs, gastroenterologists should “explicitly inform” the PCP of the patients’ unique needs, “especially those on immunomodulators and biologics or being considered for such therapy.” – by Adam Leitenberger
Disclosures: Farraye reports he is a consultant for AbbVie, Braintree, Celgene, Cellceutix, Janssen, Merck, Pfizer, PUMA, Salix, Takeda and UCB, and also reports he is a member of a data safety monitoring board for Mesoblast and Protagonist. Please see the full guideline for a list of all other authors’ relevant financial disclosures.