Health Maintenance Consensus for Adults With Inflammatory Bowel Disease

The Impact of Concomitant Hypothyroid Disease on the Course of Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, immune-mediated inflammatory disorder of the gastrointestinal tract. In IBD, systemic inflammation and immune dysregulation may also impact extraintestinal organs, such as the thyroid gland. Despite this, little is known about the influence of concomitant hypothyroidism on the clinical course of IBD.

METHODS

A retrospective analysis was conducted among adult patients with IBD and at least one thyroid stimulating hormone (TSH) measurement within a large healthcare network. Patient charts were reviewed, and baseline demographics, disease characteristics, biomarkers, healthcare utilization, medication use, and other comorbidities were extracted. Patients were stratified by those with IBD only and those with concomitant IBD and hypothyroidism. Multivariable logistic regression was used to identify factors associated with concomitant hypothyroidism. Concomitant disease as an independent predictor for lab abnormalities and increased healthcare utilization was also assessed using multivariable logistic and negative binomial regression.

RESULTS

We identified 287 adult patients with IBD, including 146 (50.9%) with Crohn's disease (CD) and 141 (49.1%) with ulcerative colitis (UC). Among this sample, 178 (62.0%) patients had concomitant hypothyroidism. Concomitant disease was associated with older age (adjOR 1.04, 95% CI 1.02, 1.06), female sex (adjOR 1.78, 95% CI 1.01, 3.16), and the presence of other extraintestinal manifestations (adjOR 2.30, 95% CI 1.06, 5.00). Concomitant disease was also found to be a significant predictor for increased healthcare utilization, specifically, higher number of radiation-based abdominal imaging (RBAI) studies (adjIRR: 1.89, 95% CI 1.08, 3.32).

CONCLUSION

Patients with both IBD and hypothyroidism have an increased likelihood of other extraintestinal manifestations compared to individuals who have IBD without hypothyroidism. Furthermore, patients with concomitant disease exhibited greater healthcare utilization, specifically, increased rates of RBAI studies. The presence of concomitant hypothyroidism may be associated with a more severe course of IBD.

AGA Clinical Practice Update on Noncolorectal Cancer Screening and Vaccinations in Patients With Inflammatory Bowel Disease: Expert Review

DESCRIPTION

The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide Best Practice Advice statements for gastroenterologists and other healthcare providers who provide care to patients with inflammatory bowel disease (IBD). The focus is on IBD-specific screenings (excluding colorectal cancer screening, which is discussed separately) and vaccinations. We provide guidance to ensure that patients are up to date with the disease-specific cancer screenings and vaccinations, as well as advice for mental health and general well-being.

METHODS

This expert review was commissioned and approved by the AGA CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. The Best Practice Advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the screening for noncolorectal cancers and vaccinations in patients with IBD. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All adult patients with IBD should receive age-appropriate cancer screening. BEST PRACTICE ADVICE 2: Adult women with IBD should follow age-appropriate screening for cervical dysplasia. Data are insufficient to determine whether patients receiving combined immunosuppression or thiopurines require more frequent screening. Shared decision making and individual risk stratification are encouraged. BEST PRACTICE ADVICE 3: All adult patients with IBD should follow skin cancer primary prevention practices by avoiding excessive exposure to the sun's ultraviolet radiation. Patients on immunomodulators, anti-tumor necrosis factor biologic agents, or small molecules should undergo yearly total body skin exam. Patients with any history of thiopurine use should continue with yearly total body skin exam even after thiopurine cessation. BEST PRACTICE ADVICE 4: At every colonoscopy, a thorough perianal and anal examination should be performed. Special attention should be made to inspection of the anal canal of patients with perianal Crohn's disease, with anal stricture, with human papillomavirus, with human immunodeficiency virus, and who engage in anoreceptive intercourse. BEST PRACTICE ADVICE 5: Gastroenterology clinicians should discuss age-appropriate vaccines with adult patients who have IBD and share responsibility with primary care providers for administering these vaccines. Patients with IBD should follow the adult immunization schedule recommended by the Centers for Disease Control and Prevention (CDC) for all vaccines with the exception of live vaccines. Patients receiving immune-modifying agents should be counseled against receiving live vaccines. Immunization history to the 2 live pediatric vaccines, varicella and measles, mumps, and rubella vaccine series, is presumptive evidence of immunity. All adults 18 to 26 years of age should receive human papillomavirus vaccine series, and those between 27 and 45 of age years should be vaccinated if they are likely to have a new sexual partner. BEST PRACTICE ADVICE 6: Inactivated vaccines are safe in patients with IBD, and their administration is not associated with exacerbation of IBD activity. We suggest that patients receive vaccines at the earliest opportunity and preferably be off corticosteroids or at the lowest tolerable corticosteroid dose. BEST PRACTICE ADVICE 7: All adult patients with IBD should be evaluated for latent hepatitis B infection. Patients who have previously completed a full hepatitis B vaccine series but are not seroprotected (hepatitis B surface antibody [anti-HBs] <10 mIU/mL) should receive a single challenge dose of hepatitis B vaccine. Four to 8 weeks after this challenge dose, their anti-HBs levels should be measured to evaluate for an amnestic response. An amnestic response, indicated by an anti-HBs level ≥10 mIU/mL (seroprotection), suggests immunologic memory, and no further doses are needed. If no amnestic response is observed, the patient should complete a second full 2- or 3-dose series of hepatitis B vaccination. BEST PRACTICE ADVICE 8: All adult patients with IBD should receive an annual inactivated influenza vaccine. Patients receiving anti-tumor necrosis factor monotherapy or who have undergone a solid organ transplant recipients can benefit from a high-dose influenza vaccine. Adults 65 years of age and older should receive a high-dose, recombinant, or adjuvanted influenza vaccine. Live attenuated intranasal vaccines should be avoided. BEST PRACTICE ADVICE 9: All adult patients with IBD 19 to 64 years of age should receive an initial pneumococcal vaccine, with an subsequent second pneumococcal vaccine administered at 65 years of age and older. BEST PRACTICE ADVICE 10: All adult patients with IBD who are 60 years of age and older should receive a respiratory syncytial virus vaccine. There is no preference for any of the available respiratory syncytial virus vaccines. BEST PRACTICE ADVICE 11: All adult patients 19 years of age and older receiving immune-modifying therapies, or with plans to initiate immune-modifying therapies, should receive a recombinant herpes zoster vaccine series, regardless of their prior varicella vaccination status. BEST PRACTICE ADVICE 12: Bone densitometry should be considered in patients with IBD, regardless of age, when risk factors for osteopenia and osteoporosis are present. These risk factors include low body mass index (<20 kg/m2), >3 months of cumulative corticosteroid exposure, current smoking, postmenopausal status, or hypogonadism. In the absence of other factors, bone densitometry should be considered for postmenopausal women and men 65 years or older. BEST PRACTICE ADVICE 13: All adult patients with IBD should be screened for depression and anxiety annually. Patients who screen positive for depression or anxiety should be referred to the appropriate specialist, be it their primary care physician or a mental health specialist.

Consensus Statements on Assessments and Vaccinations Prior to Commencement of Advanced Therapies for the Treatment of Inflammatory Bowel Diseases

BACKGROUND

Given the introduction of new advanced therapies for inflammatory bowel diseases (IBDs), expanded risk mitigation strategies are essential.

AIMS

To create a comprehensive set of statements on assessment procedures and vaccinations before starting monoclonal antibodies, Janus kinase (JAK) inhibitors or sphingosine-1-phosphate (S1P) modulators for IBD.

METHODS

We examined literature, guidelines and drug product information regarding vaccination and assessment recommendations for initiating advanced IBD therapies. Using a modified Delphi approach, delegates voted anonymously on the acceptability of these statements prior to and following consensus discussion.

RESULTS

We developed eight statements on the domains of infectious diseases screening, vaccinations and assessments prior to commencing JAK inhibitors and S1P modulators. Six statements received agreement. Pre-advanced therapy screening for infectious diseases was established, and the vaccination protocol was revised. Malignancy, cardiovascular and thromboembolic risk assessments are necessary before initiating JAK inhibitors. Those starting S1P modulators need cardiac and ophthalmic assessments.

CONCLUSIONS

These consensus statements combine vaccination and assessments on the currently available advanced therapies for IBD as a single comprehensive document that may reduce IBD complications associated with use of advanced therapies. Knowledge gaps identified during the consensus process will provide further research opportunities.

Safety and Monitoring of Inflammatory Bowel Disease Advanced Therapies

The recent approval of new medications with novel mechanisms of action and emergence of updated safety information for existing therapies has changed the treatment landscape of inflammatory bowel disease (IBD). These advances led to unique adverse effect profiles and identification of new safety signals, resulting in the evolution of the safety, monitoring, and positioning of IBD therapies. In this updated review, we (1) examine the existing and updated safety data of monoclonal antibodies and small molecules for IBD, with a focus on recently Food and Drug Administration (FDA)-approved therapies, and (2) propose risk stratification and assessment considerations prior to and during IBD treatment.

Health Care Maintenance in Pediatric Inflammatory Bowel Disease

Patients with pediatric inflammatory bowel disease (pIBD) are at an increased risk for complications and comorbidities including infection, nutritional deficiencies, growth delay, bone disease, eye disease, malignancy, and psychologic disorders. Preventative health maintenance and monitoring is an important part to caring for patients with pIBD. Although practice is variable and published study within pIBD is limited, this article summarizes the important field of health-care maintenance in pIBD. A multidisciplinary approach, including the gastroenterologist provider, primary care provider, social worker, psychologist, as well as other subspecialists is necessary.

Health Care Maintenance in Patients with Crohn's Disease

Health care maintenance is critical for patients with inflammatory bowel disease (IBD), particularly for those receiving immunosuppressive medications. Vaccination recommendations for potentially preventable diseases, cancer prevention recommendations, and assessment of bone health and mood disorders are discussed in this article. Staying up to date with health care maintenance is of utmost importance, and all gastroenterologists caring for patients with IBD should be able to make recommendations regarding preventative care of these patients.

Immunomodulatory Agents for Treatment of Patients with Inflammatory Bowel Disease (Review safety of anti-TNF, Anti-Integrin, Anti IL-12/23, JAK Inhibition, Sphingosine 1-Phosphate Receptor Modulator, Azathioprine / 6-MP and Methotrexate)

PURPOSE OF THE REVIEW

As treatment options for Inflammatory Bowel Disease (IBD) expand each class of medication will have specific safety concerns and side-effect profiles that need to be considered for optimal treatment of patients. We will review the most recent safety data for the newly approved immunomodulator therapies for the treatment of IBD.

RECENT FINDINGS

There are a growing number of publications outlining safety concerns for medications used to treat IBD. We reviewed safety profile of anti-tumor necrosis factor antibodies (TNF) with specific attention to combination therapy (anti-TNF plus immunomodulator). Recent publications have demonstrated increased risk of serious infection and malignancy (lymphoma and overall cancer rates) in patients receiving anti-TNF combination therapy when compared with patients receiving anti-TNF monotherapy or immunomodulator monotherapy. Recent publications on Janus Kinase Inhibitors indicate an increased risk of infection, specifically Herpes Zoster, and increased risk of major cardiovascular events and venous thromboembolic events resulting in a black box warning for the medication. In contrast, anti-interleukin 12/23 agents and gut selective anti-integrin antibody agents have demonstrated a favorable side-effect profile with low rates of infection and malignancy. The latest class of medications to be approved, sphingosine 1-phosphate (S1P) receptor modulators, have cardiac and infectious precautions. The field of IBD treatment is rapidly evolving with several mechanistic classes of medications now available. While corticosteroids continue to be associated with the greatest, overall, safety risks, each of the newer mechanistic classes have unique safety concerns. In the future, as we gain more experience with these agents, we will need to continue to evaluate the safety profile of our therapies used alone or in combination to make informed treatment decisions with our patients.