Health Care Maintenance in Patients With Inflammatory Bowel Disease

In this podcast, Freddy Caldera, DO, MS, speaks about health care maintenance in patients with inflammatory bowel disease, including appropriate recommendations and timing for vaccinations, cancer screenings, and psychosocial care. Dr Caldera also spoke on these topics at the American College of Gastroenterology Annual Scientific Meeting 2022 during a session titled “What else do we need to do? Health care maintenance for IBD patients.”

Additional Resource:

• Caldera F. What else do we need to do? Health Care Maintenance for IBD Patients. Talk presented at: ACG 2022; October 21-26, 2022; Charlotte, NC. Accessed October 12, 2022. https://acgmeetings.gi.org/

Freddy Caldera, DO, MS, is a gastroenterologist and an associate professor at the University of Wisconsin School of Medicine and Public Health (Madison, WI).

TRANSCRIPTION:

Jessica Bard:

Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator Jessica Bard with Consultant360 Multidisciplinary Medical Information Network.

An estimated 3 million adults in the United States reported being diagnosed with Inflammatory Bowel Disease (IBD) in 2015, according to the most recent data available from the Centers for Disease Control and Prevention.

Dr Freddy Caldera is here to speak with us today about his session at ACG 2022 titled “What else do we need to do? Health Care Maintenance for IBD Patients.”

Dr Freddy Caldera:

I'm Dr. Freddy Caldera, I'm an associate professor at the University of Wisconsin, School of Medicine and Public Health. And I'm a gastroenterologist, who has a big interest in determining immune vaccine response to vacine in patients with inflammatory bowel disease.

Jessica Bard:

We're talking about your session today. Could you provide us with an overview of your session, please?

Dr Freddy Caldera:

Yeah, so I was really excited to be selected for this, because this is definitely, a topic that I'm very passionate about. I have a Masters in Clinical Investigation from our School of Medicine and Public Health and preventative care is very important, because we can improve the lives of many of our patients with inflammatory bowel disease, but some of our therapies can increase the risk for certain complications. So, by doing simply preventative measures, we can prevent that. So, during my talk, I really want to highlight what the risk for infections are, how we can prevent those with some vaccines, make sure our patients are getting the appropriate cancer screening. And in reality, making sure that we're taking ownership for our health maintenance in our patients with IBD. Because, a lot of times, we're their main provider. We don't have to be their primary care provider, but we need to own the immunosuppressive medicine that we're prescribing them.

Jessica Bard:

So, you mentioned some vaccinations there. What are the appropriate recommendations and timings for vaccinations?

Dr Freddy Caldera:

This is obviously, a big topic for me and one of the things I highlight in my talk, is most patients with IBD can follow the regular adult immunization schedule. One, a topic that's been controversial for a while, is who is responsible for recommending and administering these vaccines? Because, primary care providers have a very hard job. They have to be semi-experts almost on everything. And as providers, the first thing we don't want to do is harm. And I've seen many cases where a young person comes in, they're on x-biologic and they get asked to take a flu shot and they can ask a simple question like, "Will that make my IBD worse?" And primary care provider doesn't know that answer. And they may say, "No." And because of that, they don't get vaccinated. Or, "When should they get vaccinated, timing to their biologic?"

And at least, we have guidance from the American College of Gastroenterology saying, that gastroenterologists should be responsible for recommending and probably share responsibility to make sure these vaccines are administered. And this is a big deal, because many studies have found that a provider's recommendation to be vaccinated leads to higher vaccine uptake. Because, we know vaccines are safe in patients with IBD, we've done a systemic review in meta-analysis, where we included the Influenza vaccine, Pneumococcal vaccine, Hepatitis-B vaccine. And patients with IBD have the same events after vaccination, just like general population. So, they don't have a risk of flare. And these vaccines are safe. And we know that patients with IBD are at increased risk for influenza, they can be at higher risk for pneumococcal disease, they're at increased risk for herpes zoster. Those are the big three, that as gastroenterologists, we need to play an active role and make sure they're getting the appropriate vaccines.

And now, most of us have heard of a COVID booster, right? And we also need to be making sure that our patients are getting their booster and if they have any questions about the safety, or when they should get one. We do have recommendations from the CDC, that you should be getting this new COVID booster. We have safety data saying that we're seeing the same side effects after the vaccination, where you might have a sore arm and you might have some chills. But, COVID isn't going away. And with our current vaccines, we can't prevent disease, but the goal is to decrease your risk of being hospitalized, or having severe complications from COVID. And that's where the new COVID booster, which is just a slight change in the vaccine that has, the new Omicron strain, just like we get a new flu shot every year, that's something that you can be doing.

Jessica Bard:

Yeah, I think it's easier to see why that's so important. And you also mentioned cancer screenings. What are the appropriate recommendations for cancer screenings?

Dr Freddy Caldera:

So, not all patients with IBD, are at increased risk for colon cancer, but if they have involvement of the colon, we need to make sure that they're getting the appropriate colonoscopies. And I think, a gastroenterologist, that's something we're really good at, because we do colonoscopies. So, that's something that's always on our mind. I think, making sure that our young women are having appropriate cervical cancer screening, that one can be a little bit harder and maybe we don't take ownership. But, there's a recent population-based study, because for a while it's been controversial, whether women with IBD are at increased risk for cervical cancer. And a new population-based study showed that they didn't see an increased risk for cervical cancer, but they saw an increased risk for low-grade lesions. Hopefully, we'll see less cervical cancer in the future, because we have a vaccine now, that can prevent cancer. How awesome is that?

You have a vaccine, which just like the human papillomavirus that can prevent five cancers. And when I talk to my young men and they're like, "Oh, I don't know if I want to get vaccinated, that doesn't pertain to me." And I'm like, "Well, it can cause penile cancer. You might want to prevent that." And as a provider, it's not only our young patients, 15 to 26, actually the human papillomavirus vaccine is now recommended from age 27 to 45, in those who may have a new sexual partner. And the vaccine works so well, that even if you're going to have a new sexual partner, you can definitely get this vaccine that could prevent cancer. So, it's definitely, something I like to recommend to my patients. And the last one is skin cancer screening.

Obviously, that's changed over the years where many people wear sunscreen. We have data from our patients with IBD, that thiopurines, or azathioprine, or 6-MP can increase the risk for non-melanoma skin cancer. So, we need to make sure that they're getting a skin exam from their primary care provider or being referred to dermatology.  Patients on Anti-TNF may have be at  an increased risk  for melanoma, so those patients should get appropriate screening.  And it’s really the immunosuppression. So, anyone who’s immunosuppressed, needs to get some skin cancer screening, whether that’s annual, or every two years. I leave that up to the dermatologist, or primary care provider, because everyone’s a little bit different.

Jessica Bard:

All really good points. Definitely, well said. We also mentioned osteoporosis assessments. So, what are the recommendations for osteoporosis assessments in patients with IBD?

Dr Freddy Caldera:

So, the reason we want to prevent osteoporosis, is because a fragility fracture is a big deal. It’s associated with big morbidity and mortality. And there are many people in the general population who could have risk factors, whether they have a low BMI, they’ve been on corticosteroids before, they’re a smoker, there are postmenopausal. There are definitely some risk factors for osteoporosis and osteopenia. But, patients with IBD have unique risk factors. If they’re malnourished, they have a vitamin D deficiency, there have been corticosteroids, where they have this underlying inflammatory state. While some of these risk factors, we really can’t modify, we can’t make someone bigger. We can treat their inflammation, but that’s where we need to highlight the many ways we can try and manage, or prevent, or treat osteoporosis. And one of the most important ones that, I think, we don’t make a big deal about, is we can have them make lifestyle changes.

If someone’s smoking, we may help them quit smoking. We should make sure they’re doing weightbearing exercises. So, young patients who’s been on corticosteroids, because their disease has been refracting and you’re trying to get them in remission, once they’re getting better, that’s definitely something we need to highlight. Make sure they’re taking appropriate calcium and vitamin D. And the biggest thing, is we just need to do DEXA screening, where there are many studies showing that our rates for DEXA screening are pretty dismal. And it’s pretty simple. I don’t think, anyone’s asking a gastroenterologist to treat osteopenia, or osteoporosis. But, at least if you find it, then you can refer them back to their primary care provider and say, “Would you recommend x treatments?”

Jessica Bard:

Now, how about psychosocial care?

Dr Freddy Caldera:

I think, this is a huge impact and that we definitely seen it with the pandemic, where many of our patients initially, since we didn’t know what the risk from COVID was, and I’ve seen some patients even become a bigger mental issue, where I tell some of my patients... I had one patient tell me, “IBD is an invisible disease, because no one knows you feel bad, because you look okay, you don’t look sick.” And I think sharing and I personally, don’t have IBD, so I can’t tell my patients, I know what they’re going through. But, just acknowledging the fact that this is a sucky disease and it’d be great if we could cure them. I think, that brings a lot, because this can affect patients in many ways. One of the ways I try and get around that, is I try to ask people what they love to do. And every time they come to an appointment, I ask them if they’re doing that.

And if they’re not doing that, I try and find out why. Is it, because their disease isn’t as good? So, they’re not going to concerts, if they love going to concerts. Or, they’re not going out as much as they want. And this is where you’re getting mental health help, either through a health psychologist, a support group, an online group. I think, a lot of my patients have found that very helpful.

Jessica Bard:

What are the gaps that exist in the research of healthcare maintenance for IBD patients? And what would you say is next for research?

Dr Freddy Caldera:

I think, there’s a lot of areas we could go and research. I think, as we get more and more therapies, we’re going to need research highlighting how these therapies impact vaccine response, especially given COVID. Where, we’re getting new therapies, but that’s not a routine part of the studies that are being done. And I think, especially if we start using these therapies as combination, that that’s going to be something that really needs to be looked at. I think, another important topic is actually, disparities. So, a lot of disparities research has been done, showing that if you’re from an underserved population, you’re less likely to get the care of someone else, whether you have less visits to the doctor, more ER visits, more hospitalizations. We know in the general population, that we learned from COVID, that initial vaccine uptake wasn’t the same, if you came from an underserved population. So, we’ve seen some of the same thing in patients with IBD.

And I think, what we have to work on, is how to close that gap, so that once you get on therapy, if there’s a way we could prevent a complication, how do we make sure you’re getting the same preventative care, if you’re from an underserved population as someone else? And we can't assume that the patient doesn't want it. We need both quality improvement research, we need qualitative research to see is it a cultural difference? Is it medical distrust? Is it many, many of the same reasons why people don't get the same care? So, I think we have a lot of work to do in that area.

Jessica Bard:

I think, that's well said. What are the overall take-home messages from our conversation today?

Dr Freddy Caldera:

I think, as gastroenterologists, we just need to play an active role and just as much as we get concerned of getting our patients in remission, I think we need to play an active role in making sure that they're doing the preventative care that they need. So, if they need to be getting a vaccine... So, for a long time, preventative care was not thought to be in the realm of a gastroenterologist, right? We were specialists and this is primary care. I think, that has shifted and you can see many notes from providers where they have a checklist and I think, the checklist is a start, where that's the minimum we should be doing. I think, now we've gone to the era where we really need to own preventative care for our patients. I'm not saying, we need to be primary care providers, but if there's certain things that they should be getting, we need to make sure that we're highly recommending, or even doing some of these things for them.

Jessica Bard:

Well, Dr. Caldera, is there anything else that you'd like to add today? Anything that we missed?

Dr Freddy Caldera:

No, no. I'd just like to thank you for having me.

Jessica Bard:

Absolutely, thank you for your time.