Non-colorectal Cancer Screening and Vaccinations in Patients with Inflammatory Bowel Disease: Expert Review.

Abstract

Description: The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice (BPA) statements for gastroenterologists and other health care 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, vaccinations, as well as advice for mental health and general wellbeing.

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 BPA statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the screening for non-colorectal 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: BPA 1. All adult patients with IBD should receive age-appropriate cancer screening. BPA 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. BPA 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 (anti-TNF) biologic agents, or small molecules should undergo yearly total body skin exam (TBSE). Patients with any history of thiopurine use should continue with yearly TBSE even after thiopurine cessation. BPA 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, anal stricture, human papilloma virus (HPV), human immunodeficiency virus (HIV), and those who engage in anoreceptive intercourse. BPA 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 two live pediatric vaccines, varicella and measles, mumps, and rubella (MMR) vaccine series is presumptive evidence of immunity; All adults 18-26 years should receive HPV vaccine series and those between 27-45 years should be vaccinated if they are likely to have a new sexual partner. BPA 6. Inactivated vaccines are safe in patients with IBD and their administration are not associated with exacerbation of IBD activity. We suggest patients receive vaccines at the earliest opportunity and preferably off corticosteroids or at the lowest tolerable corticosteroid dose. BPA 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 (anti-HBs < 10 mIU/mL) should receive a single challenge dose of hepatitis B vaccine; Four to eight weeks after this challenge dose, their hepatitis B surface antibody (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 two or three dose series of hepatitis B vaccination. BPA 8. All adult patients with IBD should receive an annual inactivated influenza vaccine; Patients receiving anti-TNF monotherapy or who have undergone a solid organ transplant can benefit from a high dose influenza vaccine; Older adults 65 years of age and older should receive a high dose, recombinant, or adjuvanted influenza vaccine. Live attenuated intranasal vaccines should be avoided. BPA 9. All adult patients with IBD aged 19-64 years should receive an initial pneumococcal vaccine, with an subsequent second pneumococcal vaccine administered at 65 years of age and older. BPA 10. All adult patients with IBD who are 60 years of age and older should receive a respiratory syncytial virus (RSV) vaccine. There is no preference for any of the available RSV vaccines. BPA 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 (RZV) vaccine series, regardless of their prior varicella vaccination status. BPA 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 (BMI; <20), greater than 3 months of cumulative corticosteroid exposure, current smoking, post-menopausal status, or hypogonadism. In the absence of other factors, bone densitometry should be considered for post-menopausal women and men 65 years or older. BPA 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.