VACCINATIONS AND INFLAMMATORY BOWEL DISEASE Bob Kizer MD Assistant Professor of Medicine Creighton University School of Medicine CONFLICTS OF INTEREST None 1
AN OPPORTUNITY FOR IMPROVEMENT IBD patients are at increased risk of cervical cancer, pneumococcal infections, and developing zoster irrespective of medication use Many patients with IBD require prednisone at immunosuppressant doses, immunomodulators, or biologic medications that can further increase risk of preventable infections Despite these risks, IBD patients appear to be vaccinated at a rate less than the general population WHY? Patients may see their gastroenterologist as their PCP Gastroenterologists may believe that vaccinations are the role of the PCP PCPs may have concerns about providing vaccinations to patients receiving immunomodulators and biologics Gastroenterologist offices may not be equipped to provide vaccinations In this region, a close collaboration between Gastroenterologists and PCPs is essential to ensure our IBD patients receive recommended preventative care 2
IT S A TEAM APPROACH THE ROADMAP What resources are available to guide decisions? Advisory Committee on Immunization Practices American College of Gastroenterology Guidelines Cornerstones Checklist What are the special cases for IBD compared to the general public? Avoidance of Live Vaccines Pneumococcus Hepatitis B Zoster 3
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WHY IS IBD A SPECIAL CASE? Steroids Prednisone, prednisolone, budesonide Immunomodulators 6-Mercaptopurine / Azathioprine Methotrexate Biologics Infliximab, Adalimumab, Certolizumab, Golimumab Vedolizumab Ustekinumab Tofacitinib WHO IS CONSIDERED IMMUNE COMPROMISED? Treatment with steroids: Prednisone at a dose of 20mg daily for 2 or more weeks Ongoing treatment with effective doses of 6MP, azathioprine or methotrexate Ongoing treatment with biologics Those within 3 months of stopping the above treatments Significant protein-calorie malnutrition Sands et al. Guidelines for Immunizations in Patients with Inflammatory Bowel Disease. Inflamm Bowel Dis 2004; 10: 677-692 6
Cliff notes version: Follow the ACIP guidelines based on age, but avoid live vaccines in the immunosuppressed, and start pneumococcal vaccines early 7
CORNERSTONES CHECKLIST CORNERSTONES CHECKLIST 8
THE VACCINE: IS IT ALIVE? Live, attenuated vaccine These vaccines use the weakened form of the virus Measles, mumps, and rubella (MMR) Varicella (chickenpox) FluMist nasal influenza vaccine Can trigger the infection in immune compromised people Killed (inactivated) vaccines Made from a protein or other small pieces taken from a virus or bacteria Injectable flu vaccine is an example Recombinant Recombinant varicella vaccine WILL THE VACCINES WORK? Vaccines are effective in people on immunomodulator monotherapy 6-MP, azathioprine, methotrexate Vaccines are less effective in people on biologics But better than nothing! 9
WHEN TO VACCINATE? Live vaccines are best given 1-3 months before starting biologics or immunomodulators If you need a biologic, you can t always wait that long So, get them before you need a biologic! GENERAL RECOMMENDATIONS FOR IMMUNIZATION OF PATIENTS WITH IBD 1. At diagnosis, all patients with IBD should have a complete review of their immunization history 2. Standard recommended immunization schedules should be adhered to (when possible) 3. Check antibody status in certain cases 4. Live vaccines should generally be avoided in immune compromised patients with IBD 10
THE VACCINES: INFLUENZA HIGHLY RECOMMENDED, ANNUALLY 36,000 deaths annually from influenza Inactivated (dead) - the shot Acceptable for the immune suppressed and non-immune suppressed (and you can not get the actual flu from this vaccine) Live-nasal spray (FluMist) Only for those not on immune suppressing medications May be given to household contacts of patients with IBD THE VACCINES: VARICELLA Chicken Pox People who are not immune to chicken pox should be vaccinated If unsure, antibody titers may be helpful Chicken pox can be a much more serious illness in adults / teenagers compared to younger children If there is no known history of chicken pox or documented immunity, then vaccination is needed BEFORE STARTING IMMUNE SUPPRESSING MEDICATIONS 11
THE VACCINES: HERPES ZOSTER Zostavax is a live zoster vaccine (LZV) which may be safe to administer with immune modulators (6 MP/azathioprine and methotrexate) Recent studies suggest the LZV is relatively safe in patient on anti-tnf alpha therapy Shingrix (GSK) is a recombinant zoster vaccine given in 2 doses, 2-6 months apart IBD specific studies are yet to be done Guidelines do not make specific recommendations regarding use in IBD or other immunosuppressed patients Risks vs. benefits THE VACCINES: PNEUMOCOCCUS HIGHLY RECOMMENDED Protects against pneumococcal pneumonia, a specific type of bacterial infection that causes severe pneumonia PPSV23 (Pneumovax) and PCV13 (Prevnar 13) PPSV23 to be given 8 following PCV13 Second dose of PPSV23 recommended 5 years after first dose 12
THE VACCINES: HEPATITIS B Hepatitis B virus Everyone should be screened for this prior to starting a biologic Hep B surface antigen, surface antibody, and core antibody Vaccination: 3 shots over 6 months Part of the standard pediatric vaccination schedule May need booster (response from infant vaccine series may wane) I generally administer in anyone who may need biologic therapy THE VACCINES: HEPATITIS A Hepatitis A virus Inactivated, safe 2 shots that are 6 months apart Many are vaccinated in childhood Currently recommended in adults at risk 13
THE VACCINES: MENINGOCOCCUS Meningococcal vaccine for meningococcal meningitis Inactivated (not live) and considered safe 1 shot First year college students living in dormitories THE VACCINES: HPV Human Papilloma Virus (HPV) for prevention of cervical dysplasia and cervical cancer 3 vaccines over 6 months Shots, inactivated and safe Recommended in all women age 9-26 Now also recommended for young men Women with IBD have a higher risk for HPV and abnormal PAP smears 14
THE VACCINES Other live vaccines are generally avoided in patients who are on immune compromising medications Anthrax Yellow Fever Typhoid live oral vaccine TB BCG vaccine Measles, Mumps, Rubella Live Polio Intranasal influenza TUBERCULOSIS (TB) Everyone needs to be screened for this prior to starting biologics (so I screen all IBD patients) Latent infection you may have been infected in the past, but the infection may not be active Biologic medications may reactivate TB More common in immigrants, incarcerated Test with PPD or quantiferon (blood test, no need for follow up skin assessment) If inactive TB is present, then treatment for TB must begin prior to starting biologic 15
CONCLUSIONS Patients with IBD are an at risk population for certain infections due to disease and immunosuppression status Keeping IBD patients up-to-date on vaccines requires a partnership between the Gastroenterologist and the Primary Care Provider Multiple online resources are available to guide immunization decisions Vaccination status should be reviewed at least annually IBD or not, GET THE FLU SHOT! I tell my patients, Live your life with common sense. Wash your hands before you touch your face holes. THANK YOU! 16