Preventive health measures in inflammatory bowel disease

Table 1 Pathogenesis of micronutrient deficiency in inflammatory bowel disease

Decreased food intake

Anorexia (TNF-mediated)

Mechanical (fistulas, post-operative)

Avoidance of high-residue food (can worsen abdominal pain/diarrhea)

Avoidance of lactose-containing foods (high rates of concomitant lactose intolerance)

Increased intestinal loss

Diarrhea (increased loss of Zn2+, K+, Mg2+)

Occult/overt blood loss (iron deficiency)

Exudative enteropathy (protein loss, and decrease in albumin-binding proteins)

Steatorrhea (fat and fat-soluble vitamins)

Malabsorption

Loss of intestinal surface area from active inflammation, resection, bypass or fistula

Terminal ileal disease associated with deficiencies in B12 and fat-soluble vitamins

Hypermetabolic state

Alterations of resting energy expenditure

Drug interactions

Sulfasalazine and methotrexate inhibits folate absorption

Glucocorticoids impair Ca2+, Zn2+, and phosphorus absorption, vitamin C losses and vitamin D resistance

Cholestyramine impairs absorption of fat-soluble vitamins, vitamin B12 and iron

Long-term total parenteral nutrition

Can occur with any micronutrient not added to TPN

Reported deficiencies include thiamine, vitamin, and trace elements Zn2+, Cu2+, selenium, chromium

Adapted from Hwang et al[21]. TNF: Tumor necrosis factor.

Table 2 Prevention of osteoporosis in inflammatory bowel disease

Non-pharmacologic interventions

Regular weight-bearing exercise

Avoiding or quitting tobacco

Limited use of alcohol

Emphasis on better nutrition, particularly on vitamin D and calcium

Employment of fall prevention strategies

Pharmacologic interventions

Calcium and vitamin D supplementation

Bisphosphonates

Calcitonin

Cautious use of hormone replacement therapy for both women and men

Recombinant parathyroid hormone (teriparatide)

Minimizing corticosteroid use with the early use of immunomodulating agents

Adapted from Ali et al[34].

Table 3 Vaccinations in inflammatory bowel disease summary (quick reference)

Vaccine	How often	Live Vaccine	Patients on Immunosuppressive therapy
Influenza (Flu vaccine)	1 dose every year	Nasal spray	Use flu shot only
Varicella(Chicken pox)	If no documented immunity: 2 doses, 4-8 wk apart	Yes	Contraindicated
Measles, mumps	If no documented immunity: 2 doses, 4 wk apart	Yes	Contraindicated
Rubella (MMR)
Zoster (Shingles)	1 dose starting at 60 yr or older	Yes	Contraindicated
Tetanus, diphtheria, acellular pertussis (Td/Tdap)	If no prior vaccination: 3 doses (0, 1, 6-12). Then 1 dose of Tdap followed by a booster of Td every 10 yr	No	Follow recommended regimen
Human papilloma virus	Female: 3 doses through age 26 (0, 2 and 6 mo)	No	Follow recommended regimen
	Male: 3 doses through age 21 (0, 2 and 6 mo)
Pneumococcal (pneumonia vaccine) for subset of patients	If no prior vaccination: (0, 2 then 5 yr) 1 dose at 65 if had prior vaccination: 1 dose 5 yr after the last dose and 1 dose at age 65	No	Follow recommended regimen
Meningococcal (meningitis vaccine) for subset of patients	2 doses, 2 mo apart	No	Follow recommended regimen
Hepatitis A	2 doses, 6 mo apart	No	Follow recommended regimen
Hepatitis B	3 doses (0, 1 and 6 mo)	No	Follow recommended regimen

Centers for Disease Control and Prevention recommended vaccines for adults 2014, modified for inflammatory bowel disease patients.

Table 4 Live attenuated vaccines with recommended times of administration

Vaccine	Before initiation of immunosuppressive therapy	Already on immunosuppressive therapy
MMR	Contraindicated if starting therapy in 6 wk	Contraindicated
Zoster	Contraindicated if starting therapy in 4-12 wk	Contraindicated
		But could consider if:
		On short-term corticosteroids (< 14 d)
		On methotrexate (< 0.4 mg/kg per week)
		On azathioprine (< 3.0 mg/kg per day)
		On 6-mercaptopurine (< 1.5 mg/kg per day)
Varicella	Contraindicated if starting therapy in 4-12 wk	Contraindicated

Adapted from Chaudrey et al[55].

Table 5 Vaccination in special populations of inflammatory bowel disease patients

Pregnancy
Category B	Category C	Category X
Influenza (LAIV)	PPSV 23	Varicella, if non-immune
		1 dose upon completion or termination of pregnancy and before discharge from health care facility.
		2nd dose 4-8 wk later.
Influenza (IIV)	Zoster
Boostrix (Tdap)	Adacel (Tdap)
1 dose of Tdap vaccine during each pregnancy regardless of immunization status	1 dose of Tdap vaccine during each pregnancy regardless of immunization status
HPV 4, HPV 2	Meningococcus
PCV 13	Hepatitis A and B vaccine
	MMR, if non-immune
	1 dose upon completion or termination of pregnancy and before discharge from health care facility.
	2nd dose 4-8 wk later.
The IBD traveler
Vaccine	Type	Travel related indication
Yellow fever	Live	Parts of South America and sub-Saharan Africa
Typhoid	Live and Inactivated	Asia, Africa, Central and South America, The Caribbean, Oceania
Polio	Live
Influenza	Inactivated
BCG vaccine	Live	Travel to highly endemic area > 1 yr
Hepatitis A	Inactivated	Central or South America, Mexico, Asia( except Japan), Africa, Eastern Europe
Meningococcal vaccine	Inactivated	sub-Saharan Africa, Saudi Arabia (during Hajj and Umrah pilgrimage)
Japanese encephalitis virus	Inactivated	Rural Japan

Adapted from Chaudrey et al[55].

Table 6 Patient health questionnaire-2

PHQ-2
Over the past month, have you felt down, depressed, or hopeless?
Over the past month, have you felt little interest or pleasure in doing things?

Adapted from Arroll et al[78].

Table 7 The 8-item Morisky Medication Adherence Scale

Morisky adherence scale question	Scoring
Do you sometimes forget to take your pills?	1 for NO; 0 for YES
People sometimes miss taking their medications for reasons other than forgetting. Thinking over the past 2 wk, were there any days when you did not take your medication?	1 for NO; 0 for YES
Have you ever cut-back or stopped taking your medication without telling your doctor, because you felt worse when you took it.	1 for NO; 0 for YES
When you travel or leave home do you sometimes forget to take your IBD medication?	1 for NO; 0 for YES
Did you take your IBD medicine yesterday?	1 for NO; 0 for YES
When you feel that your IBD symptoms are under control do you sometimes stop taking your medication?	1 for NO; 0 for YES
Taking medication every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your IBD treatment plan?	1 for NO; 0 for YES
How often do you remember to take all your IBD medications?
Rarely/Never	1.00
Once in a while	0.75
Sometimes	0.50
Usually	0.25
Always	0.00

Adapted from Trindade et al[167]. Scoring: < 6 points = low adherers; 6-7 points = medium adherers; 8 points = high adherers. IBD: Inflammatory bowel disease.

Table 8 Preventive health measures in inflammatory bowel disease

Morbidity	Preventive measures	Setting	Provider
Venous thromboembolism
Dehydration	Encourage adequate hydration	Out-patient	PCP1, Hospitalist1
	Intravenous fluids when indicated	In-patient	Gastroenterologist2
Prolonged immobilization	Encourage physical activity	Out-patient	PCP1
	Early ambulation during hospitalization	In-patient	Hospitalist1
Indwelling catheters	Limit use of venous catheters when possible	In-patient	Hospitalist1, Gastroenterologist2
Hyperhomocysteinemia	Detection and correction of vitamin deficiencies B6, B12, folate	Out-patient	PCP1
			Gastroenterologist2
Oral contraceptives	Advise on alternative methods of contraception	Out-patient	PCP1
Active intestinal disease	Anti-inflammatory treatment, monitoring of medication and response to therapy.	Out-patient	Gastroenterologist1
(inflammatory burden)			PCP2
Cardiovascular disease
Hypertension (Primary and secondary prevention)	Low sodium diet, smoking cessation, increased physical activity.	Out-patient	PCP1
	Anti-hypertensive medication
Coronary artery disease	Low sodium diet, smoking cessation, increased physical activity, screening for hyperlipidemia. Statins, anti-platelet drugs,	Out-patient	PCP1
(Primary and secondary prevention)			Cardiologist1, Gastroenterologist2
Stroke	Anti-platelet therapy, statins, Anti-hypertensive medications	Out-patient	PCP1, Neurologist2 Gastroenterologist2
(Primary and secondary prevention)
Smoking
	Smoking cessation advise, nicotine replacement therapy, smoking cessation counselling and support programs	Out-patient	PCP1
			Gastroenterologist2
Cancer
Skin	Advise on UV exposure	Outpatient	PCP1
	Protective clothing , high SPF sunscreen		Gastroenterologist2
	Yearly physician skin exam
Colon	Surveillance colonoscopy per IBD guidelines	Out-patient	Gastroenterologist1
			PCP2
Cervical	PAP smear	Out-patient	Gynecologist1, PCP2
Breast	Counselling on breast cancer awareness	Out-patient	PCP1
	CBE every 3 yr
	Mammography after 40 yr
Prostate	Counseling and Shared-decision making on PSA testing	Out-patient	PCP1
Nutritional deficiencies	Screen for and correct nutritional deficiencies	Out-patient	PCP1
			Gastroenterologist2
Osteoporosis	DEXA in patients with increased risk of osteoporosis (hx of steroid use 10 mg daily x > 3 mo) treatment with bisphosphonates if osteoporosis confirmed.	Out-patient	PCP1
			Gastroenterologist2
Infections
Vaccine preventable infections	Vaccination	Out-patient	PCP1
			Gastroenterologist2
Reactivation of Hepatitis B virus	Screening for HBV before initiating	Out-patient	Gastroenterologist1
	Anti-TNF therapy
Reactivation of latent Tuberculosis	Screening for latent TB before initiating	Out-patient	Gastroenterologist1
	Anti-TNF therapy
Anemia	Detection and treatment of anemia	Out-patient	PCP1
			Gastroenterologist2
Depression	Depression screening PHQ 2	Out-patient	PCP1
	if positive do PHQ 9 for diagnosis		Gastroenterologist2
	Mild depression -counselling
	Moderate to severe- counselling +medication
Sleep disturbance	Screening for sleep disturbance, Counseling on sleep hygiene	Out-patient	PCP1
			Gastroenterologist2
	Medical therapy
Medication related adverse effects	Assessing medication adverse effects and interactions	Out-patient	Gastroenterologist1
			PCP2
Medication Non-adherence	Screening for medication non-adherence	Out-patient	Gastroenterologist1
	MMAS-8 item questionnaire		PCP2
	Review frequency of medication refills
	Drug levels for anti-TNF and thiopurines

¹Primary role in preventive care;

²Secondary role in preventive care. PCP: Primary care physician; MMAS-8: 8-Morisky Medication Adherence Scale.