Why Talk about This? Lack of Primary Care Health Care Maintenance in the IBD Patient Sunanda Kane, MD MSPH FACG FACP AGAF Mayo Clinic Rochester Many patients with IBD are young and do not have co-morbid illnesses The gastroenterologist will often serve as their only physician Patients with IBD receive less preventive health services than general primary care patients After adjusting for insurance status, difference in screening rates lower for IBD patients than for controls (71% versus 78%; P = 0.022) Selby Inflamm Bowel Dis. 2008:14:253-258 The Newly Diagnosed Patient Lab work Procedure schedule Tobacco cessation Depression Age appropriate vaccinations Age appropriate cancer screening Laboratory Testing: Medication Dependent 5-ASA: annual creatinine Steroids: 25-OH vit D, chemistries, glucose AZA/6MP:TPMT prior, CBC and LE s weekly x 4, monthly x 3, then every 3 months after Methotrexate: CBC, LE s q 2weeks x 2, then monthly x 3, then every 3 months Biologics: PPD, Hep A, B, C prior; CBC, LE s periodically? Need for annual PPD likely related to exposure risk Van Staa Gastroenterol 2004; 126:1733-9. Lichtenstein Gastroenterol 2006: 130:940-87. 1
Tobacco Cessation Tobacco use has known cardiac, pulmonary and oncologic associated risks Negative effect on Crohn s disease Consider buproprion as alternative as has anti-tnf properties as well The College Bound Patient Vaccinations Depression Eating disorders Binge drinking/etoh abuse Johnson. Aliment Pharmacol Thera 2005:21:921-31. Vaccines For most IBD patients, recommendations do not deviate from the general population Influenza and pneumococcal pneumonia are the most common vaccine preventable illnesses in adults Exceptions: Early dosing Pneumovax Zoster Live virus Vaccines Sands et al. IBD 2004;10:677-692 Vaccinations Tetanus: one time then q 10 yr boosters HPV: females 9-26 Influenza (attenuated): annually Tdap: single booster between ages 19-64 Pneumococcal: 1 dose age 19-26, second after 5 years Meningococcal: only for asplenia, first year college students, military recruits and travelers to endemic areas Hepatitis A: 2 doses, consider checking HAV and if negative booster given Hepatitis B: 3 doses, check HBsAb, booster if negative ACIP. Ann intern Med 2009; 150:40-4. 2
Live Vaccinations* Bacille Calmette-Guérin Influenza inhaled (LAIV) (parenteral attenuated) Measles, Mumps, Rubella Typhoid (oral) (parenteral attenuated) Polio (oral) (parenteral attenuated) Vaccinia (smallpox) Varicella Yellow Fever Zoster *Contraindicated for patients on biologics or high dose steroids.? Azathioprine, MTX ACIP. Ann intern Med 2009; 150:40-4. Depression Rates range from 15-35% Associated depression decreases QoL, increases functional disability and utilization of health care Most treatments well tolerated In MN, WI DIAMOND project in primary care clinics Bernklev Inflamm Bowel Dis 2005; 11(10):909-18. Walker Am J Gastroenterol 2008; 103(8):1989-97. Cancer and Dysplasia: Cervix Recent data suggest increased risk for abnormal Pap smears in women with IBD Follow up studies have demonstrated that the use of immunomodulators is the factor behind increased risk Women on immunomodulators should undergo annual Pap testing as suggested by American College of OB/Gyn Cancer and Dysplasia: Breast Most common malignancy in US women First degree relatives of CD patients may have a two-fold higher frequency rate compared to controls Treatment tends to be less aggressive, and mortality rates higher in IBD patients Annual mammography starting age 40 Kane Am J Gastroenterol 2008; 103(3):631-6. Riegler Dig Liver Dis 2006; 38(1):18-33. Sogaard Inflamm Bowel Dis 2008; 14(4): 519-25. 3
Cancer and Dysplasia: Anal cancer Anal squamous cell ca linked to HPV No guidelines exist for IBD Chronic inflammation of anal canal, perianal disease predisposes to neoplastic changes Cancer and Dysplasia: Skin Non-melanoma skin cancer occurs 65-250 times more frequently in a patient on immunosuppression Incidence increases with duration Increased risk of melanoma controversial Data in IBD suggest an increased risk Bjorge Br J Cancer 2002;87(1):61-4. Jess Aliment Pharmacol Thera 2004; 19(3):287-93. The Patient Over 60 Bone health Hypertension/CAD Eye health Age appropriate cancer screening Osteoporosis Remember normal bone density does not impart immunity from fragility fractures! DEXA gold standard for diagnosis T score < -2.5 osteoporosis Lifestyle modifications first Smoking cessation, exercise Minimize alcohol, caffeine Adequate calcium and vitamin D Bernstein Gastroenterol 2003; 124(3):795-841. 4
Cancer and Dysplasia: Prostate 1 in 6 men in US will get prostate cancer PSA and rectal exam at age 50 Screening starts at 45 for history of first degree relative < 65 with prostate ca Health Maintenance Checklist PPD Vaccinations Radiographic exams Colonoscopy Labs US Preventive Task Force Ann Intern Med 2008; 149(3):185-91. Moscandrew M. IBD 2009; 15:1399-1409 5