Dr Abraham elaborates on dealing with issues of infection, risks of malignancy, and pregnancy when caring for patients with Crohn disease.

Bincy Abraham, MD, is a professor of Clinical Medicine and director of the Underwood Center - Fondren Inflammatory Bowel Disease Program Houston Methodist Hospital.

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TRANSCRIPT:

Bincy Abraham, MD

Hi, I am Dr. Bincy Abraham, professor of Clinical Medicine at Houston Methodist Hospital in Houston, Texas. I'm here at the Crohn's and Colitis Congress in Denver, Colorado. I just finished my keynote presentation on managing Crohn's Disease under special circumstances. We talked about managing a patient who, let's say, has been undergoing serious infections and how to choose therapy accordingly. I talked about two main infections that we are often faced with in our IBD patients.

One C.difficile infection talked about how this is predominantly seen in patients that have active disease of their inflammatory bowel disease, either in Crohn's or in ulcerative colitis. So key here is not only to treat their C.difficile infection, but also to treat their inflammatory bowel disease concomitantly. The other thing we talked about with CMV infections, similarly, we have to treat their IBD along with treating the CMV with antiviral therapy.

We also talked about treating patients that are found to be TB positive at the initiation of biologic therapy. For these patients, it's important to rule out active infection with getting a chest x-ray. If they are positive on the chest x-ray for infection, they need to be referred to infectious disease immediately for appropriate therapy. If they're just late in TB positive, meaning the chest x-ray is normal, but their quantity on TB is positive, then we should initiate therapy as well.

But in this case, we may not need to delay their IBD therapy for too long. In general, we recommend waiting about two weeks to four weeks maximum of initiating their TB therapy before starting their biologic therapy. Another circumstance that we talked about was actually pregnancy and IBD. For the most part, all the biologics that we use in IBD are actually safe to use in pregnancy based on the data that we have from our piano registry.

I recommend though that patients that are on all biologics that we have currently FDA approved except for certolizumab and vedolizumab. These patients, when they're on the medication, we need to recommend to the mom that the baby is born that at two months of age they should not get the rotovirus vaccination, which is a live vaccination. With certolizumab, because it doesn't transfer to the placenta, the baby will not have certolizumab in their body.

So it's safe to take the rotovirus vaccination. And with vedolizumab, because it doesn't suppress the immune system, the baby can safely take the rotovirus vaccination as well. The last circumstance that we talked about was actually cancer risk in IBD. We know that having active inflammation can lead to colorectal cancer, so it's important for patients to be aware that treating their underlying disease is important to prevent colorectal cancer.

On the other hand, if there is a patient who has, for example, lymphoma, we are trying to avoid therapies that can potentially increase that risk of lymphoma. So the most important medication class is the immunomodulators, thiopurines. We now have a link to increased risk of lymphoma. Anti-TNFs in general, we've seen a link with the combination of thiopurines leading to increased risk of lymphoma. However, the data is actually pretty muddled with anti-TNF therapy alone, but it is on our lower tier of using that medication, especially if there's a family history of lymphoma.

On the other hand, the newer medications such as the anti-integrins, anti-interleukin 12/23 and anti-interleukin 23s, we have not seen an increased risk of lymphoma with those medications. So we feel quite comfortable using those medications, especially if there's a concern for lymphoma in the patient. If there's a family history or a prior history in that patient. With the newer small molecule therapies such as the JAK inhibitors and the phosphate inhibitors, we don't have as much data long-term. However, we need to take into account patient's disease activity and prior use of other therapies. If it's limited to the newer agents, the new small molecules, we need to discuss at risk of lymphoma with the patient in utilizing those agents. So you consider that in a one-to-one basis.

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