When talking about health maintenance in inflammatory bowel disease (IBD), the question often arises: whose responsibility is it to ensure patients are receiving appropriate preventive care? At this year’s national Advances in IBD (AIBD) conference in Orlando, the answer was a team-based approach — starting with the gastroenterologist.
Patients with IBD do not receive preventive care at the same rate as the general population. In a busy gastroenterology practice while managing active symptoms, time is a barrier for providers to incorporate discussion about preventive care. Additionally, health care providers in both primary care and gastroenterology lack knowledge about appropriate preventive care in IBD. This gap in care has led the American College and Gastroenterology to publish clinical guidelines on preventive care in IBD patients in 2017. Many IBD patients see their gastroenterologists as their primary care providers. As such, gastroenterologists should take an active role to ensure patients are getting the preventive care they need and frequently communicate with primary care providers to coordinate care.
According to this year’s panel at AIBD, both the systemic inflammatory process and the medications we use to control inflammation in IBD contribute to the development of osteoporosis, skin cancer, and infections. Dr. Laura Raffals, an Associate Professor of Medicine at the Mayo Clinic Rochester eloquently explained how both steroids and cytokines lead to an imbalance of important molecules, RANKK and OPG, which regulate bone metabolism. Dr. Millie Long, an Associate Professor of Medicine at the University of North Carolina explained that patients with ulcerative colitis and Crohn’s disease are at an increased risk for both non-melanoma skin cancer (NMSC) and melanoma. She explained that the biggest factor for the increased risk of NMSC in patients with IBD is exposure to thiopurines and methotrexate. She also discussed that tofacitinib has been shown to increase the risk of NMSC in a dose-dependent fashion. The risk of developing melanoma, on the other hand, is increased in patients being treated with anti-tumor necrosis factor medications. Lastly, anxiety and depression often occur concurrently with IBD. Dr. Eva Szigethy, Professor of Psychiatry at the University of Pittsburgh Medical Center, discussed how systemic inflammation could directly impact brain function and mood.
Comprehensive care in IBD requires that gastroenterologists ensure patients receive appropriate vaccinations, regular skin cancer screening, cervical cancer screening for women, bone density assessment, and assessment for co-morbid mental health issues. A current checklist of these recommendations can be found on the Crohn’s and Colitis Foundation website. Aside from the general recommendations, Dr. Raffals emphasized that any fragility fracture in patients with IBD equates to osteoporosis, regardless of what the bone density is on Dual-energy X-ray absorptiometry (DEXA). Additionally, Dr. Michael Kappelman, Professor of Pediatric Gastroenterology at the University of North Carolina, emphasized that patients who have had previous shingles or received the Zostavax® should still receive Shingrix®.
The importance of preventive health care is universally accepted, yet only 23% of IBD patients are getting screened for osteoporosis and fewer than 15% of veterans with IBD are getting vaccinated for pneumococcal pneumonia. This year’s AIBD panel had some very helpful suggestions on how to improve our efforts.
First, they recommended utilizing the EHR to help track and record health maintenance measures. Providing in-office vaccinations also streamlines care and eliminates the patient’s need to depend on their primary care physician for vaccinations, which is one additional step that may lead to the breakdown of care. The use of newer technologies, such as the combination of CT enterography with a biochemical CT, can give providers information on both the intestines and bone mass. And the use of mobile applications such as “Brain Manager” may help patients in need of cognitive behavioral therapy receive the care they need even in resource-limited settings. At the University of Maryland, we have been able to implement many of these strategies. We track our patient’s health maintenance in our EHR, provide in-office vaccinations for influenza, pneumococcus, hepatitis A and B, and diphtheria/tetanus/pertussis, and screen all IBD patients with the Patient Health Questionnaire (PHQ-9) depression screen, though Dr. Szigethy recommended the use of the PHQ-2 in time-limited settings. We regularly order DEXA scans in appropriate patients and routinely counsel patients on skin cancer prevention in addition to referral for screening exams. As gastroenterologists caring for patients with IBD, we often see these patients more frequently than their primary care provider and have an intimate sense of their unique risk factors for infection, malignancy, and concurrent psychiatric disorders. General practitioners may not have this knowledge, thus failing to risk stratify patients properly. Even if the gastroenterologist cannot provide health care maintenance for patients, they can educate the referring primary care provider of the risks and/or communicate with patients the need for healthcare maintenance through receipt of written materials. It is time for the IBD community to raise the bar on health maintenance for our patients.