Health Maintenance for the
IBD Patient: Why, By whom,
what, when & how?
Sharon Dudley-Brown, PhD, CRNP, FAAN
Assistant Professor
School of Medicine
Johns Hopkins University
sdudley2@jhmi.edu
Preventive Health Issues/
Health Maintenance
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Why and by whom?
Vaccinations
Tb screening
Periodic lab testing
Colonoscopies
Tobacco cessation
Osteoporosis screening/monitoring
Other screening
How?
Why? & By Whom?
• Younger IBD patients frequently don’t
have a PCP
• PCPs rely on the specialist w/
complicated patients
• IBD patients receive fewer screening &
preventive health services compared
w/ non-IBD patients same age
Selby et al, Inflamm Bowel Dis, 2008: 14: 253-8
Vaccinations
• For most IBD patients, recommendations for
immunization don’t deviate from the general
population
– Influenza & pneumococcal pneumonia are the most
common vaccine preventable illnesses in adults
• Exceptions
– Early dosing
• Pneumococcal vaccine polyvalent
• Zoster
– Live virus vaccines
Sands et al, Inflamm Bowel Dis, 2004; 10: 677-92
Melmed, Inflamm Bowel Dis, 2009; 15:1410-6
Vaccinations
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Tetanus: on time, then q 10 yr boosters
HPV: all females age 9-26
Influenza (attenuated): annually
Pneumococcal: 1 dose age 19-26, then in 5
years
• Meningococcal: only for asplenia, first year
college students, military, travelers
• Hep A: 2 doses or check titer and boost if • Hep B: 3 doses, check HBsAb, and boost if –
ACIP; Ann Intern Med, 2009: 150:40-4
Melmed, Inflamm Bowel Dis, 2009; 15:1410-6
Live Vaccines*
• Bacille-Calmette-Guerin
• Influenza inhaled (LAIV) (parental attenuated)
• Measles, Mumps, rubella
• Typhoid (oral) (parental attenuated)
• Polio (oral) (parenteral attenuated)
• Vaccinia (smallpox)
• Varicella
• Yellow fever
• Zoster
*Contraindicated for patients on biologics, steroids,
? Azathioprine, MTX
ACIP; Ann Intern Med, 2009: 150:40-4
Melmed, Inflamm Bowel Dis, 2009; 15:1410-6
Zoster Vaccine
• Contraindicated: high dose steroids (> 20 mg/
day) for 2 or more weeks. Defer for 1 month
after discontinuation
• Therapy w/ low dose MTX (<0.4 mg/kg/week),
Azathioprine (<3.0 mg/kg/day) or 6-mp (<1.5
mg/kg/day) are not considered sufficiently
immunosuppressive and are not
contraindications for zoster
• Safety & efficacy unknown- anti-TNF agents
– Defer for one month after discontinuation
MMWR, May 15, 2008/57 (early release); 1-30
24 y.o. F w/ CD, on IFX, and HPV
positive asks you if she should
have the HPV vaccine….Do you
recommend vaccination?
1. No, HPV is contraindicated w/ IFX
2. No, too late, the HPV vaccine is
ineffective
3. Yes, some protection is better than
none
28 y.o. F w/ UC on 6-MP doesn’t
recall having chickenpox as child,
nor vaccination. Which is
appropriate?
1. Vaccinate now against varicella
2. Check VZV titer and vaccinate only if
negative
3. Check VZV titer but don’t vaccinate
even if negative
21 y.o. F w/ CD on 6-MP wants
to go to Brazil, endemic area
for yellow fever. What do you
tell her?
1. Get the vaccine before you go
2. The vaccine is contraindicated, so go
to Brazil without the vaccine
3. Don’t go to Brazil
Tuberculosis Screening
• Before immunosuppressive therapy
begins
– PPD
– Prior BCG- PPD positive x 10 years
– QuantiFERON Gold
• How often?
Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409
Periodic Lab Testing
• New patient
– CBC, liver enzymes, BUN/creat, fasting
glucose, lipid panel, vit B12, ferritin, folate,
iron, Vit D-25-OH
• All patients
– CRP, sed rate
– Vit D 25-OH
• Medication dependent
Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399409
Medication Dependent Lab
Testing
• 5-ASA: annual creatinine
• Steroids: Vit D 25-OH, glucose, BMP
• AZA/6MP: TPMT prior, CBC, LFTs weekly
x 4, monthly x 3, then q 3 months
• MTX: CBC, LFTs q 2 weeks x 2, then
monthly x 3, then q 3 months
• Biologics: Hep A, B, C, CBC, liver
enzymes periodically (q 3-6 months)
Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399409
Colonoscopies
• Multiple roles
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Extent & severity
Mucosal healing
Post op recurrence
CRC surveillance
• Surveillance for CRC begins 8-10 years after
diagnosis for colonic disease
– Those w/ PSC: immediate and annual surveillance
• Interval may be shorter than 1-2 years w/ family
history, PSC or history of dysplasia
Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409
Tobacco Cessation
• Negative effect on Crohn’s disease
and its treatment
– Reduce response to medication, increase
risk of post-op recurrence, shorten
duration of remission
• Smoking cessation is PRIMARY
therapy for Crohn’s disease
• Consider buproprion- has anti-TNF
properties
Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409
Osteoporosis
Screening/Monitoring
• DEXA is gold standard
– Osteoporosis if T score < -2.5
• Screening
– Any steroid use > 3 months; post menopausal/ > age
50; personal history of low trauma fracture
• Lifestyle modifications
– Smoking cessation, wt bearing exercise, adequate
calcium & vit D
• Bisphosphonates & other meds
– Refer to endocrinologist specializing in osteoporosis
Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409
Other Screening
• Cancers
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Cervix
Breast
Skin
Anal
Prostate
• Blood pressure
• Depression
• Ophthalmologic
Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409
Other Health Maintenance
Issues
• Contraception
• Use of NSAIDs
• Need for PCP/Medical Home
How is this implemented in
practice?
• Issues
– EMR
– Availability & ordering
– Assuring follow through
– Documentation
• Who is responsible?
– RN, APN, MD
• Measuring outcomes
Summary
• Preventive health issues are important
– Vaccinations- collect vaccine history
– Tb screening
– Periodic lab testing
– Colonoscopies
– Tobacco cessation
– Osteoporosis screening/monitoring
– Other screening