In this video, Dr Andres Yarur discusses approaches to vaccination, mental health screening, skin malignancies and osteoporosis as part of preventive care among patients with inflammatory bowel disease.

Andres J Yarur, MD, is an associate professor of medicine at Cedars Sinai Medical Center in Los Angeles, California. He is also the recipient of the 2023 Sherman Emerging Leader Prize for his research in optimizing today’s IBD therapies for better outcomes.

Transcript:

Hello, everyone. I'm Andres Yarur from Cedars-Sinai Medical Center in Los Angeles, California. In the postgraduate course, we had a talk on health maintenance in patients with inflammatory bowel disease, which is a topic that is actually very important. But at the same time, we commonly forget about it. And it's actually very important because a lot of preventable diseases can be addressed before they actually happen. And this is especially true in patients with inflammatory bowel disease who are at higher risk of developing some of these entities.

We first talk about vaccinations. The flu vaccine, it's an important part of the vaccination schedules of the population in general, but that includes patients with inflammatory bowel disease. We talked about the COVID vaccine, the importance of being up-to-date with the most recent formulation, the 2023, 2024 formulation. We talked about the fact that immunosuppression, specifically some agents such as anti-TNF and other entities may decrease the response to some of the vaccines, which is important. But at the same time, we know that vaccines, especially the mRNA vaccines, are very safe and effective in patients with inflammatory bowel disease. We mentioned that patients should have at least three doses. One of those doses must have been the up-to-date 2023, 2024 version.

We also mentioned how this is an evolving situation and it's important to be up-to-date with the most recent CDC guidelines. We then talk about herpes zoster, which has surfaced as a very important entity, especially as we use more JAK inhibitors and these drugs do increase the risk of developing an herpes zoster infection. Other than JAK inhibitors, anti-TNFs, and especially when in combination with the immunomodulators are also significantly increasing the risk of developing herpes zoster. And we do have a vaccine. We have a recombinant vaccine that is safe, it can be given while someone is receiving immunosuppression and can really prevent a very painful disease that can have not only short-term, but also long-term consequences.

We talked about the varicella vaccine. That's a live vaccine, should not be given when the patient is receiving immunosuppression. But before that, it is recommended when the serology is negative. In other health maintenance topics, we talked about osteoporosis. The fact that there are several risk factors for patients that put them at higher risk of developing osteoporosis. And the use of corticosteroids, especially long-term and specifically more than three months is a big risk factor. And even though we obviously want to avoid the use of steroids, especially long-term, sometimes they're needed and it's important to screen these patients for osteoporosis. We also talked about other health maintenance topics that are important, and one of them is skin examinations.

So even though the recommendations haven't changed, we did want to reinforce the fact that skin exams are important at least once a year with a dermatologist. Some of the drugs that we used, such as thiopurines can increase the risk of non-melanotic skin cancers. We also stress the fact that patients in IVD independently of the treatment they're on are at increased risk of developing melanoma. And skin checks are very important as prevention is critical, not only prevention, but also detecting these lesions early. The prognosis is much better if we detect the melanoma early as opposed to late when it's already metastasized. And I also stressed the fact that it's not enough to just send someone for a skin check once a year, but also do a skin check yourself when you're seeing the patient in the clinic in a routine basis and try to educate the patient for self-examination. Sometimes that's a very important tool that can help a lot. And if they see something new, something has changed in their skin to obviously consult and make sure that that's really not a malignant lesion.

Cervical cancer in women is another thing that we commonly forget. It's important in IVD because the guidelines for screening in patients receiving immunosuppression are different versus the general population. In patients receiving immunosuppression, the recommendation as of now is it really depends on the age. Patients 30 years or younger should have yearly cytology through a Pap smear. Patients 30 years or older should have both cytology and HPV checking every three years. So that's different as you may know versus patients without immunosuppression. Another important topic that we cover is depression. Up to a third of patients with IBD suffer from depression and there are some tools, specifically questionnaires that can help to screen for both depression and anxiety. But also pay attention when you're seeing someone in the clinic, when you're talking to them on the phone and look for red flags indicating that someone may be undergoing a really bad depression.

And we also mentioned that health maintenance is not just an obligation of the primary care. Physician, actually gastroenterologist should take a key role here and try to incorporate the whole team. The pharmacists with vaccines can be a great resource. Try and train your nurses when they're seeing patients with them, talking to them. And it's really a teamwork. And it's not just a single visit, but it's also a process, which I know it's a lot. But if we work as a team throughout the follow-up of the patient, I think is something that is not only very important, but also very doable.