IBD Drive Time: Freddy Caldera, DO, on Disease Prevention in IBD

Freddy Caldera, DO, PhD, and IBD Drive Time cohost Millie Long, MD, discuss the new AGA best practice advice on preventing diseases and monitoring for complications in patients with inflammatory bowel disease.

Millie Long, MD, is a professor of medicine, Division Chief, Director, Gastroenterology and Hepatology Fellowship, at the University of North Carolina at Chapel Hill. Freddy Caldera, DO, PhD, is associate professor of gastroenterology and hepatology at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin.

Reference: 

https://www.sciencedirect.com/science/article/pii/S1542356525000205?via%3Dihub

Any views and opinions expressed are those of the authors and or participants and do not necessarily reflect the views, policies, or positions of the AIBD Network or HMP Global, its employees and affiliates.

Dr Millie Long:

Hi, this is Millie Long from University of North Carolina, cohost of IBD Drive Time, and I am thrilled to introduce our guest today, who is Dr. Freddy Caldera. He is associate professor of medicine at University of Wisconsin and he really has an important area of specialty within inflammatory bowel disease, which is prevention and obviously a focus on vaccination and there's much we can do to help to prevent complications in our patients. So that's what we're going to be talking about today. Welcome to the program, Freddy.

Dr Freddy Caldera:

No, thanks for having me. Millie. Always glad to talk about prevention. It's such an important aspect of our patients, especially once we're getting them better and we're talking about their therapies, making that individualized is a key to their health.

Dr Long:

Oh, I agree. And I feel like it's so important too. It gives them something they feel like they can own, that you're on this therapy, there's some prevention aspects that we need to do to help to keep you healthy and prevent complications. And so I think it helps them to feel that they're doing everything they can to help to optimize and be healthy on their therapies. And so I agree with you completely. And one of the things we'll talk about today is you were the senior author on a recent document that is a CPU, a clinical practice update, published in Clinical Gastroenterology and Hepatology. This really focused on noncolorectal cancer. We're not necessarily talking about dysplasia, surveillance scopes, screening, and vaccinations in patients with IBD.

So we are going to dig into this document, but I think one of the other things we'll do is talk a little practically for our listeners in terms of how do we implement this? This can be hard to review all of these things. When's the best timing? What can we do practically to make sure we're reaching our goals of optimizing prevention? So will you talk a little bit about the structure? So this is done in something called best practice advice. Is that right?

Dr Caldera:

Yeah. And really the whole goal of this, we really wanted this to be able to hit everyone, whether you're an IBDologist, whether you're a general gastroenterologist, we wanted to make a concise document that you really could look at what's the appropriate cancer screening I should doing, what vaccines am I supposed to do? And even some of the figures that the great staff at the AGA, at CGH, were able to put together makes it a very concise way that you can hang up in your clinic and talk with your nurse, talk with your pharmacist, or talk with your advanced practice provider to say, hey, this is what you should be doing.

Dr Long:

No, absolutely. I think that makes it really practical to just say, okay, here's what I refer to. And even generate order sets based on that and other things. Now in your practice when you're focusing on the prevention side of things, is this something that needs to be brought up every visit or is there a better timing for this? Or how do you go about approaching if you have a long list of things that need to get done, making sure it gets done for the patient, but still staying on time with your visits?

Dr Caldera:

And I do build it into every visit because every time's different. So definitely during respiratory season I'm talking to patients about getting their flu shot and we have vaccine in clinic, just like I know you do, because we see our patients a lot. So just making sure things are easy, getting their flu shot, getting their COVID— when someone's getting better—and I do that regardless of are they on steroids, are they a flare because you don't have time, you just got to give them the vaccine. Once I'm getting better and I'm seeing my healthy follow-up visits when I prep for clinic, I'm like, oh, have they had Shingrix? Are they eligible for RSV vaccine? And telling them like, hey, what is RSV? And explain that to them. If they're healthy now, and they've been on corticosteroids, they had DEXA screening, are they on a thiopurine and has anyone done a skin exam? And definitely not doing full body skin exams in clinic, but I'm talking to them about that and definitely just in general about once they're getting to become older adults, they've had IBD for a while, about are they getting the appropriate cancer screening and making sure like, hey, does your primary care know you? I'm not your primary care, but what else are you doing? And that's how I stagger things because it would be daunting to do this at every visit and basically you wouldn't be able to do it.

Dr Long:

No, absolutely. So stepwise approach and really emphasizing the importance of the patient. I like that. Linking it to, well now it was respiratory season, et cetera. So that that's a really good idea. I do the same. One of the things I've found is that we actually stock all of these vaccines in clinic and that has been helpful. Now, from a reimbursement perspective, I don't lose money, I don't make money. It's more of a service that I provide for our patients because at least in my practice, I've found if I tell them, go get these vaccines, they really aren't probably going to do it. But I think the more you tell them and communicate with their primary care doctor, I think the more likely they will. But certainly, at least for some of these, it may be reasonable in your own practice to have at least flu vaccine or pneumococcal vaccine.

I've also found sometimes that the internists look at these often young people with IBD and think, oh, they're healthy. And so they don't really think, oh, they should qualify for pneumococcal vaccine or they need Shingrix vaccine. And so I think sometimes that knowledge isn't necessarily there because often our patients are young and inflammatory bowel disease is their only chronic medical problem and sometimes they don't even have a primary care doctor, but that's another problem.

All right, so let's jump in because I want, there are basically 13 BPAs as part of this document, and so I want to run through each one and let our listeners know some best practice advice for implementing that in clinic or perhaps how you bring it up with a patient. So what the best practice number 1 has to do just more broadly with screening. Is that right?

Dr Caldera:

Yeah, it's just making sure that you're getting the appropriate cancer screening. And when we're talking about this, it's also a good time to allay any concerns people have about their therapy. At times there's inappropriate concerns that anti-TNFs or other biologic therapies are necessarily linked to solid organ cancer. And I say, no, they're not, but you should go have appropriate breast cancer screening if you're that age and making sure kind of later concerns about their therapy, but say, hey, you should be doing this anyway.

Dr Long:

So this is more, you should get all the health maintenance that someone of your age gets in regular practice, but use it—I like that—as a tip to remind people, no, your therapy doesn't have any increased risk of solid organ tumors, but you still need a mammogram because everybody needs one at a certain age. So that's great. And so the second one was specific to women in regard to cervical dysplasia.

Dr Caldera:

And this is a great time to think about, did you get the HPV vaccine, right? We have, contrary to news, we have evidence that HPV prevents cervical cancer and making sure if they didn't get it, that now it's up to age 27 to 45. And cervical cancer screening has also changed where now you can do cytology and it can be very different where you don't necessarily need to be getting a pap every year. So just making sure that is being recognized. And it depends. Also, thankfully we've had more research that it's more abnormal paps rather than cervical cancer. Right.

Dr Long:

Yeah, no, and I think that's important. I think in the past when there wasn't as much knowledge or much advanced cytology and HPV testing done, it was, oh, you should probably have a pap every year. But I think that one key take-home point is that's not necessarily the case. It's individualized, it's shared decision. It's based on their individual risk factors and what their cytology shows. Correct?

Okay, great. And so the next one is actually a favorite of mine. I've done some research in this arena, but it has to do with skin cancer. And I think that all of us who've seen patients with IBD have recognized that we do see skin cancers. And you had mentioned even earlier in the program that azathioprine is one key aspect to this. We do know that's photosensitizing and as perhaps we have less of a practice with azathioprine, perhaps some of this will improve, but our other medicines can also be associated with this risk. Not all but some. So talk us through what we should be advising and how we bring up skin cancer with the patient.

Dr Caldera:

I think once someone is more stable and they've been on therapy for a bit, that's when I definitely bring this up. And I definitely say, you should be following up with either a dermatologist or talk to primary care. Are they comfortable doing a whole body skin exam? And I'm like, this is not just looking at your back. This is you're naked and everyone's, someone's looking everywhere. And that's where we have a lot of data from transplant that it's the modification of the immune system that I think we need more research, just like what you've done, just saying there's data from JAKs, from RA, looking at risk of skin cancer that I think over the next few years we're going to see that it's not all therapy, but definitely there are some signals with different therapies and we have to modify that risk and it also depends what they do. So I love trying to build a connection with people and see what they do. So my patient who repairs air conditioning all day, I'm like, you need skin cancer screening because you're out all the time. Versus the person that has an office job and doesn't have any hobbies that make him go outside, that's very different. So I specifically try and target based on what people's hobbies are and their jobs are too, to remind them of why it's important.

Dr Long:

No, I think that's a great point to kind of understand the baseline risk with sun exposure. So number 4 is that at colonoscopy, a thorough perianal and anal examination should be performed. So talk us through this one.

Dr Caldera:

And this is, well this is a tough one that I haven't done as much and this is where I want to improve and I've been looking at anal cancer screening. So I mean we don't have a great statement and I think the tough one is no one really owns this, where we do perianal exams at colonoscopy, but this is something that I think over the years we're going to need to pay more attention. Ray had a great article in the red journal talking about anal cancer in patients with IBD. So I think we just need to take time and think of this in someone either with perianal disease, also solid organ transplant, or anyone with HIV, I think we need to start thinking about more anal cancer surveillance and at least start with a digital rectal exam even if you're not sending people to get cytology and anything else.

Dr Long:

No, I agree. I think that this is something that can be missed and we just need to be really thorough and think about it from that perspective. And there are obviously, I collaborate with some of our ID doctors and our colorectal surgeons who, particularly for high-risk groups, will actually even do anal pap smears and also do high-res evaluation with endoscopy. And so I think there are things to do should we have a concern if we see something abnormal that would be important to refer for.

So Freddy, the next several, and so I'm going to lump all of these together, really kind of 5 through really 10 or actually 11. So many of these are vaccine-focused because that is obviously a prevention. So the next several of our statements have to do with that. Will you just summarize simply what those recommendations are for specific vaccines?

Dr Caldera:

Yeah, and then one quick thing to remember is regretfully, we're in an era where there's some lack of trust from vaccines and as gastroenterologists people might feel like it's not my job, but I have the feeling that we own the biologic, we know why people need a biologic or a JAK or whatever they're on, whatever their immune-modifying therapy, and our patients trust us. So I think we have to kind of own this. And one tidbit to remember is that while people might say, hey, I don't want the flu shot, if you start talking to them about shingles, they're willing to get that.

Dr Long:

Especially if they know someone who's had shingles because that can be, it's obviously so painful and it can recur. And I've found that to be a motivating factor when they know someone who's had shingles.

Dr Caldera:

Or someone got hospitalized or they'll get their flu shot, but they won't get COVID. So when you think of these recommendations, always keep that in the back of your mind.

Dr Long:

I think you're right, just because they refused one, we shouldn't say, okay, they're not going to take vaccines. I think it's a matter of emphasizing each and every one because there are some that people will be willing to take, especially if you explain the rationale.

Dr Caldera:

And eventually, what I found over the years, is eventually then they'll take everything.

Dr Long:

You've got to wear 'em down, right?

Dr Caldera:

Well, you build their trust.

Dr Long:

Yeah, no, exactly.

Dr Caldera:

And they do it because kind of like the high level. So the big things that have come out recently that maybe people aren't aware of is if you're over 65, there's different vaccines because people above 65, especially this year, influenza is going rampant. So people should be getting a vaccine that's intended for older adults.

Dr Long:

Is it higher dose?

Dr Caldera:

Yeah. So there's 3 types. There's a high-dose, there's a recombinant, so you should be getting that. Also anyone with IBD who has a solid organ transplant should be getting a higher dose vaccine. And that came from the ACIP. Those on anti-TNF monotherapy, we did a study that showed better response so that you should be considering. Definitely you should still be getting a COVID booster. Lots of data of the impact of COVID. We also talked about RSV and I try and tell people, hey, this is what we knew about RSV before, we never tested for RSV, over the years we learned RSV is as bad as influenza for older adults. And we have a study showing that you're at increased risk to be hospitalized for RSV if you have IBD. So kind of bringing that up and talking about the options.

Dr Long:

And that's kind of a newer recommendation because the vaccine is somewhat newer, but it's age 60 and up for our listeners, is that correct?

Dr Caldera:

Yeah, it's 60 and up. So it's for 75 for everyone and it's for 60 to 74 if you have a risk factor for severe disease, which is being hospitalized. So in IBD, we have that, so someone can confidently say, if you have IBD and you're 60, you should get an RSV vaccine. For now it's just once, eventually, just because it's a respiratory virus and then we will have waning immunity from it, people will probably get a booster, but we'll need more data on that.

We also highlight pneumococcal. So pneumococcal vaccination is always supercomplicated, and right now there's 2 pneumococcal vaccines. There's the PCB 20 and PCB 21. You can still get PCB 15, but we kind of wanted to simplify this and just say, hey, PCB 20 and PCB 21, it's kind of like a one and done deal that way if you get it, you're done. You don't have to worry about when you separate it out and you're good. And just so the audience knows now, PCB 20 is actually our pneumococcal vaccination is recommended for everyone 50 and up for the general population, just because of the..

Dr Long:

That is new because it was 65. Okay.

Dr Caldera:

Yeah. So anyone who's listening to the podcast who's 50, make sure you're get PCB 20.

Dr Long:

Yeah, yeah. We all have to get but from an IBD perspective, it's really kind of 19 and up. They need an adult booster. So essentially when we see them, we should be getting them a booster, at least now one done a PCV 20 or 21 because of their risk factor of having IBD and immunosuppression. Correct?   

Dr Caldera:

Yep. And also once they turn 65, they should get an additional pneumococcal vaccine. And in there we provide you in the figure of how long you should wait. If you recently received that for people above 65, it's a shared decision, but we felt the overwhelming literature showing that older adults above age 65 can be at risk for serious infections. Getting a pneumococcal vaccine was definitely worthwhile.

We also talk about Shingrix, the recombinant herpes zoster vaccine, which is available for everyone 19 and up and making sure you talk to patients about that, about the risk of zoster with different therapies, making sure to finding different ways they can get the vaccine, whether you have it in your clinic or using a pharmacy. And I think we’ve got some work to get that done reminding patients that they will feel bad after vaccination. And just because it's bad after the first one doesn't mean the second one is worse, so that they can just plan ahead to get that.

Dr Long:

No, I agree. I always counsel patients because they often do feel almost like flu-like symptoms the night, so it's a good one to time. And so I don't ever want to surprise anyone with that one. But I think that just to emphasize for our listeners now, anyone on immunosuppression age 19 and up should actually be getting the Shingrix vaccine series. So you don't need to wait until age 50, like the general population. We want to prevent this before it happens, and there is no need to check any kind of varicella antibody. You just give it to everyone. And so that I think is quite simple and I think this is important and we've got to figure out how to operationalize it.

So that is a lot. But that is good. And just for our listeners, there are great figures and statements and a chart that shows what you should and shouldn't give. And this will be really helpful for those in your clinic who are seeing these patients.

I just wanted to take a brief moment to remind our listeners that we are sponsored by the AIBD Network and the Gastroenterology Learning Network and that the AIBD, the Advances in IBD regionals meetings are gearing up and that the first regional is actually April 5th to 6th in Nashville, Tennessee. Great site for a meeting. The cochairs of this series are Ray Cross from Mercy in Maryland, and Tina Ha from Mayo Clinic in Scottsdale, and they've put together a great program. So please register if you can go, and these are free to join.

I also want to remind our listeners that these podcasts are available not only through the AIBD Network, but also on and on iTunes.

So with that, Freddy, I wanted to round out our last couple of best practice advice for our listeners, and these have to do with bone density and then also depression. Will you talk us through these two?

Dr Caldera:

Yeah. And with bone density, I think this is something we all need to improve on because it doesn't take that much prednisone for someone to make sure you're evaluating for osteopenia or osteoporosis and checking a vitamin D because the tapers we typically use once someone gets hospitalized, that usually merits bone density screening. So A, they're incorporating a way to get this done locally or something is very important.

And obviously figuring out how your patients are doing. And that's where an easy way to do this is just seeing just at every appointment, just have a quick check-in with them and knowing since we see these people, well, how are things going at work? Whether their hobbies, are they not doing it? Some people have built in bigger health systems, have built some of these screening systems into their Epic and into their surveys they've done. But if you're not at a big system like that and you're like, how can I even get this? Something we've done, I've done before, it's like, I know Patient X loves doing this, and I always ask him, hey, how are these things going? Because IBD and being a chronic illness, there's a lot of high risk of depression and anxiety and we need to treat that just as much as we treat the active disease.

Dr Long:

No, I agree. And there's some great online resources. Not everyone is lucky enough to have a psychologist in their clinic, but there's a website called Psychology Today where you can look up psychologists who specialize in chronic diseases in your area. We found that to be a good resource. And then the Rome Foundation actually has a great directory of psychologists who specialize in chronic GI conditions and the depression and anxiety that can go with that. So I would encourage you to recognize this and then use some electronic tools for referrals, which is what we do here at UNC as well. So Freddy, these are great advice. Hopefully our listeners have a series of thoughts of how they can implement this in their practice in a slow fashion, not having to get everything done all at once. And of course, I want to direct our listeners to the publication, which is online now in clinical gastroenterology and hepatology, and it also linked on the AIBD network website.

So Freddy, before I let you go, we don't let anyone out of here without a special question. So I want to know, is there something that our listeners may not know about you that you would like to share that is unique and different, whether it's a hobby or something else that we can learn about you?

Dr Caldera:

So I love going on vacations and planning trips. My secret talent is always finding very good places to eat, whether I'm going with my kids, I have 4 kids, so whether me and my wife are planning a trip or doing, I love finding excellent places to eat.

Dr Long:

Oh, that's great. This is great. The next time I am at DDW, I'm going to ask Freddy where to eat. And so now all of our listeners are going to come up to you and ask for that advice. That's wonderful. That's a good special talent. I have no such talent, so I'll have to lean on yours.

Thanks again for joining us, Freddy, and talking about such an important aspect of prevention for our IBD patients, and hopefully we'll have you back on the program in the future to teach us more.

Dr Caldera:

Yeah. Well, thanks for having me. It's been a pleasure.