Health Maintenance

Introduction

A crucial part of caring for ulcerative colitis (UC) patients is implementing good health maintenance practices, including those aimed at preventing complications from the disease itself, as well as minimizing adverse reactions associated with administered medications. Patients often have a strong relationship with their gastroenterologist and may turn to them for their primary care needs. In fact, their gastroenterologist may be the only physician some patients see, considering them their primary provider of care. A recent study found that patients with inflammatory bowel disease (IBD) do not receive preventative services at the same rate as general medical patients of the same age.

As such, it is crucial for gastroenterologists to clarify with patients the limits of a specialist’s responsibilities and the importance of seeing a primary care clinician. However, it is equally important for gastroenterologists to take a proactive role in the health care needs of their UC patients. This section reviews the most common primary health maintenance issues that can potentially complicate UC, including vaccinations, tobacco smoking, osteoporosis, hypertension, depression, malignancies and others. A health maintenance checklist is provided in Table 14-1 and a list of clinical guideline recommendations from the American College of Gastroenterology (ACG) is provided in Table 14-2.

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Vaccinations

Due to use of long-term immune-suppressive therapies, including corticosteroids, immunomodulators and biologic agents, patients with UC are at increased risk for developing infectious complications, many of which are preventable with vaccination. Unfortunately, studies indicate that many immunosuppressed patients are inadequately vaccinated. In one study of 145 patients with IBD on current or previous immunosuppressants, only 28% reported regular flu shots and only 9% received the pneumococcal vaccine. This problem is not helped by the observation that both gastroenterologists and primary care physicians are hesitant to take ownership of the vaccination responsibility. In one survey of 108 gastroenterologists, 65% believed the primary care physician was responsible for determining which vaccines to give and 83% believed the primary care physician was responsible for administrating the vaccines. However, family care physicians are often uncomfortable with making vaccine decisions for their IBD patients. The ACG suggests that vaccine recommendations be the responsibility of the gastroenterologist, but that their delivery be shared with the primary care physician.

Other reasons for low rates of vaccination among patients with IBD include lack of patient awareness and fear of adverse effects. A common concern among patients and clinicians is that vaccinations will exacerbate IBD disease activity. However, several studies have failed to demonstrate an associated between IBD activity and vaccination. In one study, 575 patients on immunomodulators or anti-tumor necrosis factor (TNFs) received the H1N1 vaccine and absence of flare was observed in 96.7% of patients with CD and 95.6% with UC within 4 weeks of vaccination. These rates were considered consistent with the background rate of relapse.

Although vaccine recommendations in patients with IBD are fairly straightforward, there appears to be poor knowledge among gastroenterologists regarding which vaccines are recommended. In the survey of 108 gastroenterologists, 20% to 30% would incorrectly give live vaccines to immunosuppressed patients whereas 25% to 35% would incorrectly withhold live vaccines from immunocompetent patients. In general, age-appropriate vaccine schedules should be followed. At the time of IBD diagnosis, vaccinations should be reviewed and brought up to date, even if immunosuppressive therapy is not immediately planned. Conversely, delaying some vaccinations may be required if prompt immunosuppressive therapy is required.

Non-live vaccines can be administered to all adult patients with IBD regardless of immunosuppression status, in accordance with national guidelines published by the CDC, the Advisory Committee on Immunization Practices (ACIP) and the Infectious Disease Society of America (IDSA). The ACG recommendations for non-live and live vaccines are shown in Table 14-3 and Table 14-4, respectively. Similar recommendations for live and inactivated vaccines have been published in 2021 by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association. Live vaccines, including the measles, mumps and rubella vaccine, the varicella vaccine and the herpes zoster vaccine (Zostavax is a live vaccine; Shingrix is a non-live vaccine) have special considerations. In general, live vaccines should not be administered once immunosuppression is initiated or within 4 weeks prior to initiation.

Vaccination rates can be improved in clinical practice by implementing certain office measures, such as the systematic education of healthcare professionals and making the influenza and pneumococcal vaccines available at the gastroenterologist’s office. In one study, the introduction of checklists significantly improved vaccination rates in IBD patients. A simple checklist is provided in Table 14-1. Other checklists can be found at:

• https://www.cornerstoneshealth.org/wp-content/uploads/2019/05/Checklist-for-Monitoring-Prevention-2018.pdf
• https://www.crohnscolitisfoundation.org/sites/default/files/legacy/science-and-professionals/programs-materials/health-maintenance-checklist.pdf

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Tobacco Cessation

The associated between smoking and an increased risk of complications in Crohn’s disease (CD) is well established, with the ACG strongly recommending CD patients to be counseled to quit. However, the relationship in patients with UC is less well established. One study found that active smoking in patients with UC had beneficial effects, indicated by reduced rates of colectomy, primary sclerosing cholangitis and backwash-ileitis in active smokers compared to never smokers. In addition, higher daily cigarette dose correlated with less extensive colitis and a reduced need for therapy. Smoking cessation after diagnosis in patients with UC was detrimental, indicated by an increased need for steroids and hospitalization. If such findings are true, then the clear benefits of smoking cessation on other aspects of patient health need to be weighed against the possible risk of exacerbating UC symptoms.

Osteoporosis

In patients with osteoporosis, increased bone fragility and fracture risk are major causes of morbidity and mortality and have significantly associated costs. Osteoporosis has become recognized as a relevant medical issue in patients with IBD since they have an increased risk for loss of bone mass. For every 10% drop in bone mineral density, the risk of fracture risk increases two to three times. The pathogenesis of osteoporosis in patients with IBD is multifactorial and not completely understood, but likely results from a combination of the systemic effects of chronic inflammation, calcium and vitamin D deficiencies, glucocorticoid use, as well as other factors.

Estimates place the prevalence of osteoporosis in patients with IBD to be between 14% and 42%. Not all patients with IBD are a similar risk for developing osteoporosis—there are certain risk factors associated with the development of accelerated bone mineral loss, osteoporosis, and fracture. Current ACG guidelines recommend that patients with conventional risk factors for abnormal bone mineral density with IBD undergo screening for osteoporosis with bone mineral density testing at the time of diagnosis and periodically after diagnosis. Risk factors for osteoporosis other than low bone mineral density include advanced age (≥65 years in women, ≥70 in men), low body weight (<132 pounds), major weight loss (>10% below weight at age 25), sedentary lifestyle, vitamin D deficiency, malabsorption, current smoking, high alcohol or caffeine intake, postmenopausal state, glucocorticoid exposure (>3 consecutive months with a dose of ≥7.5 mg/day of prednisone-equivalent), family history of fractures, history of adult fracture, history of falls or increased risk of falling and others.

The gold standard for diagnosing osteopenia and osteoporosis is dual-energy absorptiometry scanning (DEXA), the results of which can be used to guide therapy. Osteoporosis is diagnosed on a result of a low bone mineral density of ≥2.5 standard deviations below the average in gender-matched young adults (a T-score of less than -2.5) or if a patient sustains a fragility fracture, defined as a fracture from a fall from standing height or less. Osteopenia is less severe and defined as low bone mineral density (BMD) with a T-score of -1 to -2.5. For patients with a T-score above -1, treatment recommendations are preventative and include weight-bearing exercise, calcium and vitamin D supplementation, limiting caffeine and alcohol use, discontinuing medications that affect perception and balance (eg, antihistamines, antipsychotics, benzodiazepines, tricyclics) and minimizing corticosteroid use.

The AGA finds glucocorticoid use, in addition to advanced age, as the strongest risk factors for reduced bone density. The greatest bone loss occurs during the first 6 months of the initial course of corticosteroids; therefore, an effort should be put into minimizing glucocorticoid use, with steroid-sparing agents used when necessary. In patients with osteopenia (T-score of -1 to -2.5), the above preventative measures should be implemented and DEXA should be considered 2 years later. Bisphosphonates are recommended for patients with osteoporosis, history of a traumatic fracture, or failure to withdraw from corticosteroids after 3 months. Secondary causes of low bone density (e.g., celiac disease, vitamin D deficiency, hypogonadism) should also be evaluated in patients with osteoporosis or who sustain a low-trauma fracture.

Blood Pressure Screening

Hypertension (≥140/90 mmHg or ≥130/80 mmHg for patients with diabetes or chronic kidney disease) affects approximately 50 million individuals in the United States. Patients with UC are at increased risk for secondary hypertension due to the adverse effects of certain medications, notably corticosteroids and cyclosporine. Discontinuation of these agents should be considered in patients presenting with hypertension. If these medications are required, then health-promoting lifestyle modifications are the first approach to management. Such approaches include weight reduction, adoption of a Dietary Approaches to Stop Hypertension (DASH) eating plan, reduction of dietary sodium, increased physical activity and moderation of alcohol consumption. If antihypertensives are needed, the Joint National Committee (JNC) recommends starting with a thiazide agent. Calcium-channel blockers are also well tolerated and may have the added benefit of slowing bone demineralization in osteoporotic patients.

Depression Screening

The etiology of disease activity following periods of remission is complex and likely involves the interaction between a variety of genetic and environmental factors. Psychological factors, such as anxiety and stress, have been reported as contributing factors by both patients and caregivers. The chronic relapsing nature of the disease, as well as medication side effects, are likely partly responsible for the negative impact on patient psychological well-being. In a systematic review, anxiety was present in 19% of patients with IBD vs 9.6% in the non-IBD population, whereas depression was found in 21.2% and 13.4%, respectively. Of concern, rates of depression were similar between groups of patients with and without active disease. The presence of psychological disease in patients with IBD is associated with poor health-related quality of life, self-perceived functional disability, reduced compliance and increased resource utilization. As such, the ACG recommends screening for depression and anxiety in all patients with IBD. Screening for depression has been shown to be accomplished effectively by asking two brief questions, as recommended by the American College of Preventive Medicine (ACPM):

• Over the past month, have you felt down, depressed, or hopeless?
• Over the past month, have you felt little interest or pleasure in doing things?

Promising results have been demonstrated after treating depression in patients with IBD. In a review of 12 studies, antidepressants were effective at treating both psychological and somatic symptoms in patients with IBD. In one study of 29 IBD patients (14 with UC) and matched controls, patients had fewer relapses and courses of steroids the year after starting antidepressant therapy, whereas controls showed no change. Although not all gastroenterology practices will be equipped to treat depression, it is important to at least recognize the increased risk in IBD patients and to refer patients when definitive diagnosis and treatment is required.

Ophthalmologic Screening

Ocular involvement in IBD is common, including inflammatory conditions such as uveitis, scleritis and episcleritis. These inflammatory processes may or may not be related to the activity of the underlying inflammatory bowel disease. Patients taking corticosteroids may develop cataracts and glaucoma and have temporary vision changes while on this medication. Patients complaining of eye pain or vision loss should be referred for evaluation, since some complications can lead to permanent vision loss. Other ophthalmologic manifestations have been reported in IBD patients, including conjunctivitis, optic neuritis and retinal vasculitis, thus routine ophthalmologic examinations are recommended.

Cancer Screening

Colorectal Cancer

Patients with longstanding and extensive UC (as compared to isolated limited proctitis) have an increased risk of colorectal cancer (CRC) compared to the general population. Accordingly, surveillance colonoscopy is recommended every 1 to 2 years in patients with disease of at least 8 years duration to obtain biopsies to look for any signs of dysplasia. Due to an even greater risk of CRC in patients with UC and concomitant primary sclerosing cholangitis (PSC), surveillance colonoscopy is recommended at the time PSC is diagnosed and then yearly thereafter. When using standard white light endoscopy (WLE), at least 33 biopsies should be obtained (usually four biopsies every 10 cm from the cecum to the rectum) for increased sensitivity for detecting dysplasia.

Increasingly, chromoendoscopy (CE), using topically applied dyes such as methylene blue or indigo carmine applied to the colon during colonoscopy, has been advocated to more accurately detect dysplastic lesions and perform targeted biopsies rather than random biopsies. High definition endoscopes and narrow band imaging may also help to identify lesions and are receiving wider use and closer attention. While CE requires additional training and leads to increased procedure time, it may allow for fewer biopsies and higher detection of dysplastic lesions in patients with UC undergoing surveillance colonoscopy. We can expect additional data regarding this and other newer endoscopic techniques to further augment the optimal methods for UC surveillance procedures.

The 2019 ACG clinical guidelines for UC management in adults suggest colonoscopic screening and surveillance to identify neoplasia in patients with UC of any extent beyond the rectum. When using standard definition colonoscopes in patients with UC undergoing surveillance, the ACG guidelines recommend dye spray chromoendoscopy with methylene blue or indigo carmine to identify dysplasia. When using high definition colonoscopes, the guidelines suggest using white-light endoscopy with narrow-band imaging or dye spray chromoendoscopy with methylene blue or indigo carmine to identify dysplasia.

Cervical Cancer Screening

Infection with the oncogenic human papilloma virus (HPV) is the greatest risk factor for cervical neoplasia. Other known factors associated with an increased risk of cervical cancer include tobacco use, age, nutritional status and a suppressed immune system. Data supporting an associated between just having IBD and an increased risk of cervical dysplasia are conflicting; however, there is a more established link in patients on immunosuppressants. A recent Danish study of over 26,000 women with IBD found that women with UC had an increased risk of low-grade (IRR=1.15) and high-grade lesions (IRR=1.12) compared to healthy controls. In patients with IBD on immunosuppressants, a meta-analysis found an increased risk of high-grade dysplasia and cancer (OR=1.34). Additionally, data suggest that women with IBD, particularly those on immunosuppressants, are screened less frequently than the recommended period of 3 years in healthy women.

The CDC currently recommends HPV vaccination for all boys and girls at ages 11-12 to protect against HPV-related infections and cancers. Adults up to age of 45 may also decide to get vaccinated. However, many females will have been exposed to HPV before they are vaccinated, so regular screening is the best approach to protect patients from cervical cancer. The ACG recommends annual cervical cancer screening women with IBD on immunosuppressive therapy.

Skin Cancer Screening

Two malignant complications associated with the use of thiopurines and anti-TNF therapies have been recognized: 1) an increased risk for nonmelanoma skin cancers (NMSC) associated with past or current thiopurine use and 2) the potential for melanoma in patients with IBD exposed to anti-TNF therapy. There is also a risk of melanoma in patient with IBD independent of medication use. The ACG therefore recommends that patients on immunomodulators should undergo screening for NMSC while using these agents, especially when over the age of 50 and that patients with IBD undergo screening for melanoma independent of the use of biologic therapy.

Sun protection (e.g., sunscreen use and sun protective clothing) and dermatological surveillance strategies (eg, regular skin self-examinations and physician skin examinations) are advised for all patients with IBD. Patient should also be advised on the importance of rapidly contacting their physician upon noting skin abnormalities.

Laboratory Examinations

Patients with IBD require periodic blood test monitoring, the type and frequency of which will depend on their medication and comorbid conditions. A basic panel for all patients includes an annual complete blood count, creatinine and liver function tests, including AST, ALT, alkaline phosphatase, total bilirubin and albumin. Lipid levels should be monitored annually; total and LDL cholesterol may be low in patients with active disease, but high lipids may be present in patients with inactive disease. Nutritional supplementation may be required in certain patients, especially in those with more severe disease. Annual monitoring of iron, folate, serum albumin, vitamin D and vitamin B12 can help guide vitamin and mineral replacement. These recommendations are for patients not taking any medication for their condition. Medication-specific recommendations, in addition to these tests, should be performed. For more information on these additional tests, refer to the treatment section of this module.

Patient Education

Patients who are well informed about their condition are more likely to adhere to therapy and health maintenance measures. Example patient-friendly educational resources from reputable sources are provided in Table 14-5. Informing patients about their condition and providing them with educational resources gives them the best chance to understand UC, its treatment and the importance of the discussed health maintenance measures.

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