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Health Maintenance for the IBD Patient: Why, By whom, what, when & how?

Health Maintenance for the IBD Patient: Why, By whom, what, when & how?. Sharon D udley-Brown, PhD, CRNP, FAAN Assistant Professor School of Medicine Johns Hopkins University sdudley2@jhmi.edu. Preventive Health Issues/ Health Maintenance. Why and by whom? Vaccinations Tb screening

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Health Maintenance for the IBD Patient: Why, By whom, what, when & how?

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  1. 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
  2. Preventive Health Issues/ Health Maintenance Why and by whom? Vaccinations Tb screening Periodic lab testing Colonoscopies Tobacco cessation Osteoporosis screening/monitoring Other screening How?
  3. 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 ageSelby et al, Inflamm Bowel Dis, 2008: 14: 253-8
  4. 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
  5. Vaccinations 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
  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
  7. 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 discontinuationMMWR, May 15, 2008/57 (early release); 1-30
  8. 24 y.o. F w/ CD, on IFX, and HPV positive asks you if she should have the HPV vaccine….Do you recommend vaccination? No, HPV is contraindicated w/ IFX No, too late, the HPV vaccine is ineffective Yes, some protection is better than none
  9. 28 y.o. F w/ UC on 6-MP doesn’t recall having chickenpox as child, nor vaccination. Which is appropriate? Vaccinate now against varicella Check VZV titer and vaccinate only if negative Check VZV titer but don’t vaccinate even if negative
  10. 21 y.o. F w/ CD on 6-MP wants to go to Brazil, endemic area for yellow fever. What do you tell her? Get the vaccine before you go The vaccine is contraindicated, so go to Brazil without the vaccine Don’t go to Brazil
  11. 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
  12. 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 dependentMoscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409
  13. 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: 1399-409
  14. Colonoscopies Multiple roles 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 dysplasiaMoscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409
  15. 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
  16. 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
  17. Other Screening Cancers Cervix Breast Skin Anal Prostate Blood pressure Depression Ophthalmologic Moscandrew, Mahadevan, Kane, Inflamm Bowel Dis, 2009; 15: 1399-409
  18. Other Health Maintenance Issues Contraception Use of NSAIDs Need for PCP/Medical Home
  19. How is this implemented in practice? Issues EMR Availability & ordering Assuring follow through Documentation Who is responsible? RN, APN, MD Measuring outcomes
  20. Summary Preventive health issues are important Vaccinations- collect vaccine history Tb screening Periodic lab testing Colonoscopies Tobacco cessation Osteoporosis screening/monitoring Other screening
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