Gil Melmed, MD, on Health Maintenance for Patients With IBD

Dr Gil Melmed talks with Drs Raymond Cross and Millie Long about the importance of vaccines, cancer screenings, and other aspects of overall health maintenance for patients with inflammatory bowel disease.

Raymond Cross, MD, is a professor of medicine and director of the IBD Program at the University of Maryland School of Medicine in Baltimore. Millie Long, MD, is a professor of medicine, vice chief of education and director of the fellowship program in the Division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill. Gil Y Melmed, MD, is director of Inflammatory Bowel Disease Clinical Research and codirector of the Clinical Inflammatory Bowel Disease program at Cedars-Sinai Medical Center in Los Angeles, California.

TRANSCRIPT

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

Raymond Cross:

Welcome everyone to IBD Drive Time. I'm Raymond Cross from the University of Maryland School of Medicine. I'm here with my cohost as always, Millie Long from University of North Carolina, and we're delighted to have Gil Melmed from Cedars-Sinai. Gil, welcome to IBD Drive Time.

Gil Melmed:

Thanks so much, Ray. It's a pleasure to be here.

Raymond Cross:

So our topic today is going to be health maintenance, and Gil, I wanted to jump right in and ask you about what our current vaccine recommendations are for our patients with IBD.

Gil Melmed:

Thanks Ray. Yeah, so there's a bunch of recommendations. There was a publication by the ACG put out a number of years ago now, some of which are outdated or have been updated, with respect to vaccines that we would give patients for IBD. And I like to think of it as we have 3 major respiratory infections, including COVID now, and then 3 that start with an H. So we have our 3 recommendations for respiratory infections that include influenza vaccination, which is important for our patients with IBD on an annual basis. We have the pneumococcal vaccination against several strains of pneumonia, and actually there's been updates in the pneumococcal vaccines that have been available over the last few years. And then we have COVID of course, and we shouldn't forget about COVID when it comes to health maintenance because patients who may not have received COVID vaccination as time goes on, we'll need to make sure that we are updating our patients with respect to COVID vaccine.

And then we have those three that begin with an H. We have hepatitis B vaccination, we have HPV, human papillomavirus, and then we also have-

Raymond Cross:

Herpes zoster.

Gil Melmed:

Herpes zoster. Thank you. I'm thinking that's a Z, not an H.

Raymond Cross:

Gil. That's great. And you've also taught me that the 3 respiratory infections that you mentioned are of course going to be the most common infections that our patients with IBD get.

Gil Melmed:

Indeed.

Raymond Cross:

What about inactivated versus live vaccines? So any live vaccines that our patients are going to get exposed to and any contraindications for our patients on advanced therapies?

Gil Melmed:

Well fortunately most of the vaccines that we think about routinely are not live vaccines, and that includes all of the vaccines that I mentioned earlier, the respiratory vaccines, hepatitis B, human papillomavirus, COVID vaccination, and zoster are not live vaccines. And so all of those would be appropriate to give patients irrespective of the medications that they're on.

That being said, there are some live vaccines that we do need to consider, predominantly in children, where we do need to think about patients who are on "immunosuppression". What that means, probably patients who are on steroids, those that are on maybe anti-TNF therapy, and then perhaps some of the other biologics, although the guidelines from the CDC suggest certainly those that are on steroids or those that are on immune suppression with anti-TNF therapy. These are situations where there's theoretically a risk of that live vaccine harboring a virus that could actually cause infection. A live virus vaccine is essentially a vaccine with a weakened virus that's been weakened in the lab, and then the virus has been engineered so that it doesn't cause infection, but it may actually theoretically cause infection in those with compromised immunity.

Raymond Cross:

And I think this comes up most often for us. Our patients, often 2 weeks before they're going to travel, say that, "I need X vaccine-"

Millie Long:

Like a yellow fever vaccine.

Raymond Cross:

A live vaccine, and how do I handle that?" Fortunately, I've had a situation where I've gotten some lead time and I've been able to hold a dose of infliximab and give them the vaccine and then restart and it's been successful, but that can be a big challenge.

Gil Melmed:

So just to call them out, in kids who need to get their MMR vaccine, who need to get their varicella or even babies exposed to anti-TNF therapy in utero with the rotavirus vaccine a couple of months after birth. So those are live vaccines that we do need to think about predominantly.

But you're right. When it comes to adults, I think the one that most commonly comes up are adult patients who travel and those are going to endemic areas in Africa or South America where yellow fever vaccination may be mandatory in order to enter those areas. So then it becomes a real conundrum. What do we do about those patients being able to travel to those areas safely without vaccination? Are we willing to give them a waiver of vaccination and risk a yellow fever? The potential theoretical risks of that vaccine in an immunocompromised individual can also be very significant. So it presents a dilemma that I often involve a travel medicine consultant with.

Raymond Cross:

Now I want to come back to Shingrix. But before I get there, there were obviously a lot of opinions with the COVID vaccine and concerns and in general, sometimes our patients have concerns about worsening IBD after a vaccine. Is that something that they should be worried about?

Gil Melmed:

In short, no. There may have been some case reports early on with influenza vaccination and others suggesting that perhaps immune-related conditions might be activated with the immune response. However, what we've learned from larger case series and control trials even is that there does not seem to be an increased risk of certainly IBD flare after vaccination. Actually, Millie, in your cohort, you showed that very nicely with your cohort of over 3000 patients receiving COVID vaccination that there was no signal for activation of IBD. And other cohorts around the world have shown similarly.

Millie Long:

Right, no, absolutely. And I think you just have to keep in mind that there's a background risk of relapse of IBD and what that is. And so certainly there may be some cases, but that's what one could expect. And in large cohorts, the COVID vaccine is not associated with exacerbation. There have actually been some nice studies on some of the other vaccines. For example, the HPV vaccine had a nice longitudinal study that showed no exacerbation. Even the zoster vaccine. Frank Ferrer did a series, as well as there was a series in the VA, that showed no increased rate of that background exacerbation with that vaccine. So I think we can safely say that we're not seeing this immune reactivation phenomenon, and our patients should not be concerned about that and really maximize some of the preventive benefits.

I will say I just recently reviewed some of the data on pneumococcal vaccine and I was so impressed. There was a nice study out of the VA that looked at severe pneumococcal disease, so getting hospitalized with whatever it may be, a pneumonia, meningitis, et cetera. And the odds ratio for prevention if you had the appropriate pneumococcal vaccination series was 0.1. I have never seen something that protective. So the idea is by giving our patients these inactivated vaccines, we can really prevent major downstream consequences.

Raymond Cross:

But just remind me, if I'm remembering this correctly, the one problem is that it was vastly underutilized in the population, right?

Millie Long:

Well, and Gil's done some of that work to show that unfortunately, we're not meeting the rates we need to for our vaccination.

Gil Melmed:

Right, yeah. We published, at least in our local community, the rates of pneumococcal vaccination were less than 10% because we're dealing primarily with a younger population. And oftentimes the primary care providers don't think about this vaccine unless the patient perhaps has asthma or some respiratory condition, or they're over the age of 60, 65. So I think that it's a real educational hurdle that we've had to get over, over the last number of years really, to push the notion that our patients are at risk. They're at risk for pneumococcal disease, they're at risk for pneumonia. And actually some of the most severe infections that occur in biologic agents are with pneumonia. And so I think it really behooves us to be thinking about how to protect our patients as best we can.

Raymond Cross:

It's really a perfect segue. So you mentioned primary care. So Millie and I wanted to talk about pragmatically how this is done. So is this the primary care provider or pediatrician's job? Is it the gastroenterologist's job? Is it a collaboration? When are you doing it? Are you doing it before they start advanced therapy? Practically, how do you do it in your clinic?

Gil Melmed:

Yeah, I think that's going to probably vary from place to place depending on the setup. A private practice might be different than an academic healthcare setting, part of a larger health system, a large community practice. So there may be different aspects as to who's in charge of that primary care vaccination series, who's really up-to-date on the latest guidelines with the medications that we use for IBD. I think what's absolutely critical is that there's communication, and it's three-way communication. It's the gastroenterologist or the gastroenterology team, it's the primary care provider, and it's the patient.

So when I see a patient in my own clinic, I have a hard stop in my electronic medical record that forces me to address this issue to think about it. So I can quickly run through it and see the patient's vaccine schedule, but I also have an opportunity to talk to the patients about it. And of course it's in my template, so it goes in my note, which goes to the primary care provider as well. So I make sure that the patient knows and that the primary care provider knows what my recommendations are. We don't administer the vaccine in our clinic. So it's really providing the recommendations to the patient and to the primary care provider as to what I'm recommending based on the medications that they're on.

Millie Long:

And I think that's a great model and it's a practical model. I do think sometimes there's a misstep because the patient has to be activated to ask their primary care physician about it. So I think just revisiting at multiple visits I think can help. The other thing is for many of these vaccines, they can go to a Walgreens or some sort of pharmacy, a CVS, and actually just get them there. And so giving them an order to do that is one other option.

One of the things we do in our clinic is we actually do keep these vaccines in clinic. And I know that's a luxury. We don't make any money on them, but we don't lose any money on them. It's a service that we have for our patients. And that's been really helpful, particularly for zoster vaccine, because of the new age. Now individuals aged 18 and up who are on immunosuppression are eligible for zoster vaccine, and not everybody knows that yet. I think it's been harder to send people out to have that particular vaccine done. So we have had some. It's been advantageous to have it in our clinic from that regards.

Gil Melmed:

Yeah, Millie, I'm really glad you brought up zoster vaccine because I think you showed us this in the study over 10 years ago that our patients with IBD are at significant risk for zoster. The risk of an IBD patient in their 20s for zoster is probably similar to the general population in their 60s. So what that means is that we really need to be thinking about this potential infection because it's reactivation of the chickenpox to which everybody's either exposed to as natural infection or as a vaccine.

Then we also have to think about the fact that some of our newer therapies, such as JAK inhibitors, have been associated with higher risks of zoster than we've seen previously. And so thinking about zoster vaccination in basically all of our patients, particularly our younger patients who are starting a JAK inhibitor, is something that's also been practice-changing for me.

Raymond Cross:

Our clinic functions much like Millie's does at UNC where we can actually give not all of the vaccines, but many of the vaccines. And I think one thing to highlight is we can't do everything in a visit. So oftentimes our trainees are starting to delve into health maintenance in a patient who's having an exacerbation of disease, and I'm like, "Okay, hold on." Our job is to get their disease under control first. This is a long distance run. This is a marathon. This isn't something we need to do right now. And certainly never delaying starting an advanced therapy to get a vaccine, unless it's some essential live vaccine where maybe you could justify. But in general, get their disease under control and then focus on things thereafter.

So before I turn it over to Millie, I just want to remind our listeners that IBD Drive Time is sponsored by Advances in IBD and the Gastroenterology Learning Network. And a reminder that there is a virtual IBD coming up September 14th and 15th. We encourage you to register and attend that excellent course. And now I'm going to turn it over to Millie for the last few questions.

Millie Long:

Great. Well, Gil, the last couple of questions I have are actually separate from vaccines because they're more than just vaccines in terms of health maintenance. Our list keeps growing in terms of those things we want to address with our patients. So I was just wondering if you could address some of the other aspects. What else are you thinking about in terms of health maintenance outside of vaccines?

Gil Melmed:

Yeah, I think it's important to bring up other things. In particular, it's cancer screenings. And so which cancers do we need to be thinking about? There's skin cancer screening. Again, another study, Millie, that you taught our community was that our patients are at risk for non-melanoma skin cancer and perhaps even melanoma. And the question is, who are those patients and what are the medications that we need to think about? Particularly those that are on thiopurines do need to be considered for non-melanoma skin cancer risk.

Then perhaps there's a signal with anti-TNF therapy and melanoma. So for patients who are on those medications, I do recommend that they see a dermatologist annually for skin checks and also advise sun precautions by making sure they understand the importance of sunscreen, of covering up in the sun, and not getting sunburned, because that does increase the risk of all of those skin cancers.

In addition, pap smears for women and perhaps for men. I think that the male risk of HPV and HPV-associated cancers has been underappreciated, but the recommendations, coming back to the vaccines for HPV vaccination, is for women and men that are up to age 26, and in some people perhaps up to age 45. So we do need to think about that potential risk, making sure our female patients are getting pap smears and perhaps our male patients, particularly men who have sex with men, are also getting anal pap smears in order to screen for HPV-associated cancers.

Then, of course, we as gastroenterologists need to be thinking about our patient's dysplasia risk in their colons. And just to remind the audience is that it's not just ulcerative colitis, it's also Crohn's disease when it involves the colon, and particularly that involving more than a third of the colon, when we do need to be thinking about dysplasia surveillance for our patients and doing adequate colonoscopy surveillance for those patients.

In addition to cancer surveillance, I think another healthcare maintenance issue that we do need to be thinking about is bone health. In which patients should we be getting a DEXA scan replacement with calcium and vitamin D? Certainly those that have been on extensive steroid use in their lifetime, those that have experienced significant malnutrition, as well as other just chronic debilitating disease are people that I think about for who I'm going to screen with a DEXA scan and making sure that they're adequately repleted.

Millie Long:

Do you have any kind of protocols in your clinic? Do you check vitamin D once a year on everyone? You live in a very sunny place, so you might be okay from a vitamin D level standpoint, but do you standardize this or is it mostly just risk factor based?

Gil Melmed:

Yeah, I think even in Southern California, vitamin D deficiency is very, very common. Maybe that's because we're all wearing sunscreen or should be, but yes, I do check vitamin D. I would say that it's part of my annual labs, but I'm probably checking it more often in patients for whom I'm a little bit more worried. And then repleting, usually I'm going to replete with 50,000 units once a week with someone who is vitamin D deficient, really to just try to give them a boost, and then perhaps maintain them once they've reached normal levels of vitamin D over 30, with 1000 to 2000 units a day.

Raymond Cross:

I'm glad you brought up, Gil, anal pap smears, and I'm sure the gastroenterologists listening to this are shuddering to think that we're asking them to do anal pap smears. But we do forget, or maybe we haven't forgot, but patients who have HPV-related illnesses, men who have sex with men, patients with perianal Crohn's, have a higher risk of anal cancer. And I think we can do a little bit more as gastroenterologists. So even if you're not going to institute pap smears in your practice, which I completely understand, what we started to do at Maryland is at least once a year, do a careful perianal exam and do a digital rectal exam to see if we can feel an early mass. And it's been prompted by two of my patients who developed anal cancer. So it's really changed my practice. So we can't forget about that high-risk population.

Millie Long:

And one other thing I would encourage our listeners to do is it's not uncommon in Crohn's to get a anal canal stenosis that we have to dilate. But I think just being cognizant of that. I have patients that come back for regular dilations and probably every other time or every third time, we should be thinking about biopsying that, just to make sure that this isn't developing into any kind of dysplastic lesion. Because I too have had in our practice malignancies develop out of those strictures and people that are seen fairly regularly with dilations. So just don't forget to biopsy.

Gil Melmed:

Absolutely. I couldn't agree more. I think we're sometimes afraid to biopsy in that area, but patients can be biopsied safely. And if you're worried about it, then refer them for a proctology evaluation and biopsy because those, in fact, can harbor dysplasia and cancer that we may miss.

Millie Long:

Well, gosh, we ran the gamut today. We talked everything from vaccines to cancer screenings, and it makes you realize that we have a lot on our plate when caring for our patients with IBD. But attention to these details and potentially, as Ray mentioned, during more healthy well visits and not obviously during the acute exacerbation time, can really help to improve their outcomes.

So Gil, we'd like to thank you for your knowledge in this arena. But we always end with our fun question and I'm excited to hear what you're going to tell us, because we want to learn something about you that Ray and I and our listeners don't already know that would be interesting.

Gil Melmed:

What I'll share with you is that I'm a musician at heart. I learned to play the cello as a kid, and I played the cello throughout high school and college, and then took a break until my kids started playing music. And then playing with them has just been an absolute pleasure. But really, during COVID, our hospital put out a call for healthcare workers who were musicians and had a chance to, and have subsequently had a chance to play music with colleagues on a regular basis, which is just an absolute joy.

Millie Long:

That's fantastic. And we've learned a lot about a lot of great musicians on IBD Drive Time.

Raymond Cross:

We have a IBD band.

Millie Long:

We need to have the IBD band. At some point, we'll have the IBD band join us on IBD Drive Time. So thanks again, Gil, and thanks again to our listeners. Hopefully you'll tune in to our next episode of Drive TIme.