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IBD in Primary Care

Sandra Quezada, MD, Tom Robertson, MD, and Neda Frayha, MD
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In this segment, Dr. Sandra Quezada teaches Tom and Neda about the importance of specific health maintenance components in the care of patients with inflammatory bowel disease. We primary care providers can feel empowered to take great care of these patients without sending them back to their gastroenterologists for true primary care needs.

 

Pearls:

  • IBD health care maintenance is not significantly different. If immunosuppressed, remember vaccination against pneumococcus.

  • Colon cancer screening is more intensive in those patients who have significant colon involvement, but otherwise IBD patients do not require more intensive screening.

  • For those patients on immunomodulators, either the primary care provider or GI may be monitoring a CBC, CMP, ESR/CRP every 3 months. GI should also monitor drug and drug antibody levels.

 

  • Diagnosis:

    • Constellation of symptom, lab, imaging and endoscopy/biopsy findings

    • IBS (irritable bowel syndrome) is not the same as IBD (inflammatory bowel disease)

  • Vaccines: safe and do not flare disease activity

    • If NOT on immunosuppression, follow the same vaccine schedule

    • If on immunosuppression they may also need:

      • Pneumococcal vaccine (13 and 23 valent)

      • Best to start before they start immunosuppression but still effective even after they have started

    • Immunosuppression = equivalent of 20mg per day for at least two weeks or immunomodulators

      • Mid-level - thiopurine medications (azathioprine, mercaptopurine, methotrexate)

      • Next level biologics - infliximab, adalimumab, vedolizumab

  • Cancer screening:

    • Breast - same guidelines but they do have a higher risk of breast cancer (especially those with Crohn’s)

    • Prostate - same guidelines but IBD may elevate both PSA levels and prostate cancer risk

    • Skin - same guidelines; higher rates of melanoma in those with IBD potentially related to biologics use

    • Colon: only patients with significant colon involvement are at increased risk and warrant more screening. After 8 years onset of symptoms, these patients would start colonoscopy every 1-2 years (or more depending on level of inflammation)

  • Drug monitoring:

    • If on immunomodulators, every 3 months they should have:

      • CBC to make sure not over-suppressing and causing leukopenia

      • CMP to ensure no hepatotoxicity

      • ESR and CRP to give some objective data around inflammation

      • Drug levels and antibody levels → done by GI

 

REFERENCES:

Selby et al. IBD J, 2008

Melmed et al, AM J Gastro 2006

Sands et al, IBD 2004

CDC ACIP Recommendations 2011

Nielsen et al, Scand J Gastro 2001

Melmed et al, Gastro 2008

Ding et al, MMWR 2014

Sogaard et al, IBD 2008

Smith RA,  CA Cancer J Clin, 2008

Long et al, Gastro 2004

Itzkowitz et al IBD 2005

Heller A. Eating Right with IBD. 2004

Bonci L. American Dietetic Association Guide to Better Digestion. 2003

Alexandra P. -

Can I clarify that live vaccines are also acceptable in immunosuppressed patients? I was under the impression that most vaccines are fine but live vaccines (MMR, varicella, shingles) are contraindicated.

Neda F., MD -

Hi Alexandra. From Dr. Quezada: "Live vaccines are NOT acceptable in immunosuppressed patients. We recommend giving them to any patient for whom you anticipate beginning immunosuppression, before the immunosuppression treatment begins, but not after. Other point of distinction is Shingrix is not a live vaccine, and while it has not yet been studied in the immunosuppressed at this time it is not considered contraindicated in immunosuppressed patients, so our patients on immunosuppressive therapy DO get Shingrix (but not Zostavax)." We hope this helps! -- Neda

Gretchen A., DO -

How about cervical cancer screenings in IBD patients? Is there any reason to have more frequent paps?

Neda F., MD -

Hi Gretchen. According to ACOG, it looks like cervical cancer screening recommendations are the same as they are for the general population, and there is concern that these women are not undergoing even this standard level of screening (https://www.ajog.org/article/S0002-9378(11)01297-X/fulltext). However, there is also some literature suggesting the need for more frequent (e.g., annual) screening in women who are immunocompromised (https://www.sciencedirect.com/science/article/pii/S0889854513000211?via%3Dihub). For now, ensuring that our patients don't fall behind on standard screening seems the way to go. -- Neda F.

Neda F., MD -

Gretchen, I also checked in with Dr. Quezada, and here's her response: "We don’t screen anymore frequently than the gen pop recommendations for pts w IBD on immunosuppression or not, but we stress the need to adhere to the ACOG guidelines, just as you said!" Hope this helps! -- Neda

Suzanne W. -

How often would you give a young person the pneumococcal vaccine?

Neda F., MD -

Hi Suzanne. Based on guidelines: "Pneumococcal pneumonia: All patients with IBD should be vaccinated once with the PCV13 followed by the PPSV23 (first dose after 8 weeks if immunocompromised, or after ≥1 year if immunocompetent; second dose after 5 years; and third dose after 65 years of age). If previously vaccinated with the PPSV23, then the PCV13 should be administered at least 1 year after the PPSV23 in both immunocompromised and immunocompetent adults." From: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5114511/

Margot M. -

Do the immunosuppressed IBD patients need the high dose flu vaccine, or are they ok with the regular dose?

Neda F., MD -

Hi Margot. Regular dose is what's been studied and should be adequate. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852234/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5114511/ for added reading in case you're interested. -- Neda

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