Melissa Ferrari provides prevention techniques and vaccination recommendations for various health conditions in IBD.
I'm happy to introduce melissa Ferrari Melissa is a physician assistant working with Dr Conn Nigerian doctor Metro at the Scripps clinic focusing primarily on the management of patients with IBD melissa and have you take over. Thank you so much. Hello everyone. Welcome to the advanced practice provider track as he just introduced. I'm Melissa Ferrari and I work at scripts. I'm sure we can all agree are inflammatory bowel disease patients are exceedingly complex and it can take a lot to get them into remission. But once we do have them there there are still so many things that are important for us to remember to keep them well. And that's what I'm going to talk to you about today. Health care, maintenance maintenance in IBD. Yeah, I do not have any disclosures to report. Okay, so a little bit about my agenda in this discussion, I will start with infections. Move on to osteoporosis, screening, malignancies, depression anxiety screening and then smoking cessation as well. I think it's important for us to remember when we are able to identify a preventable disease we should act because prevention is key in primary prevention. That's exactly what we do. So when we have vaccinations as many of my colleagues have talked about, we should promote them and go through with our patients when they are due or overdue with secondary prevention for our diseases that perhaps we know could occur are screening programs are very important and we should be using them for early disease detection and then for tertiary prevention. These are the measures that we can impart to hopefully reduce the impact of long term disease and disability and extend our patients lives. Yeah, so are patients with IBD are at an increased risk for infections due to their underlying disease malnutrition surgery and or their immuno suppressed status. That diagnosis all adults should have a review of their vaccinations and proceed with updates if needed. Live vaccinations should be avoided in patients with certain levels of immuno suppression. The killed or inactivated vaccines do not present a risk of infections to patients on immuno modulators or biologics, immuno suppression. And what I found really helpful is that the christians and Religious Foundation actually provides a checklist for patients which is very easily found online so we can make sure everyone up to speed up where they should be. We do recommend to all of our IBD patients, the seasonal non live influenza vaccination annually and that would be the injectable version from a Numa cockle vaccination standpoint, routine guidelines for our over patients over 65. But for those who are planning to start immuno suppressive therapy. I did want to share this guideline with you. So in patients planning to start for those who are immunocompromised. We do recommend both the PCV 13 and the PPS. V 23 vaccinations starting with the 13 2-12 months later. The second vaccination with 23 and then repeating every five years What I have encountered in my practices that sometimes patients just can't recall which ones they've received and thus if you can see, well perhaps they have received the 23 already and you just don't have documentation of prior pneumococcal vaccine. You can go back wait at least a year after the PPS V23 vaccination to give the 13 and then continue with their routine series. But yeah herpes Zoster is quite prevalent even for not talking about IBT so the U. S. General population ask for the C. D. C. Says there's a lifetime risk of one in three people. That's pretty alarming and the incidents in IBD. The IBD population is even more so the recombinant Zoster vaccine RCD is recommended in all patients over 50 years old. And there was an update stating and in the IBD guidelines we also recommend all of our individuals on immunosuppressant immuno suppression. Independent of age. Also received this vaccination. It is a two shot series. Um The second one given 2 to 6 months later we have encountered some barriers to getting our younger patients. These vaccinations, especially those on immuno suppression. Well specifically those but we have found when we link it to certain diagnosis codes such as immuno suppression, it does tend to help other vaccinations that are important to consider hepatitis A and B vaccines are patients should be screened for both. Hepatitis the hepatitis B virus before initiating a biologic or immunosuppressive therapy and those who are seronegative should be vaccinated. I also want to take a moment to talk about how important it is to check for hepatitis B core antibody as when you're starting immunosuppressive therapy. If a patient is hepatitis B core positive, it means that they've been exposed to the virus and they could reactivate. So you do want to make sure you get that with your routine, the hepatitis B serology ease other vaccines like you're teed up HPV meningococcal he should be given with the same indications as a general adult population vaccination schedule And there are HPV vaccinations. Male and female 11-26 years old and it's a three shot series. Moving on to osteoporosis and our screening and management The prevalence and IBD is approximately 15%. We do find that male and females have about a similar risk with cortical steroid use as the strongest risk factor. The overall relative risk factor is 40% greater than that of the general population. And this risk has increased with age, all patients should receive education and the importance of lifestyle changes. As I'm sure we all educate our patients on just the overall importance of a good diet, healthy healthy exercise. You also want to point out specifically weight bearing exercises that could promote healthy bone density and maybe offset the effects of certain medications to be used in the future. As well as well as the importance of smoking cessation Preventative measures should be taken in all patients who are on predniSONE at doses greater than 5-7.5 mg a day for over three months considered Texas scans to see if any bone density loss has occurred. Perhaps even start calcium and vitamin D. Daily to help offset. And then in your patients where you've identified that bone density loss has occurred. We do often referred to endocrinology to determine the proper treatment. Uh huh. Moving on to malignant screenings starting with cervical cancer. There were a meta analysis, observational studies of women in IBD on immuno suppression and the risk of cervical cancer and dysplasia, cervical dysplasia and cancer. And it did show that there was an increased risk compared to healthy controls. And thus we have a couple of guidelines to review in general, women with IBD should receive their first pap smear by age 21 with repeat every three years until age 65. That's just in general for IBD. We found that women with HIV organ transplant history or long term immuno suppression should receive their first pap smear at the onset of sexual activity. Um with screening twice within the first year and then annually. This data does come from organ transplant populations. And that immuno suppressive risk. But the A. C. G. Did also put out their guidelines stating that women on immuno suppression should have annual pap smears. So I'm going to base more of this malignancy risk skin cancer risk based on the medications that we use. Um It is general that we have all of our IBD patients. see a dermatologist once a year due to a known increased risk. But I'm gonna be talking specifically about the risk we see with the different medications. So and sc non melanoma skin cancer. We do seem to be driven mostly by thigh appear ians which are your is a dia print or more captive hearing. Well we see melanomas tend to be more driven by our anti TNX which is more your inflict. Some ab dilemma mob as two examples our screening guidelines clearly to protect themselves sun protective clothing, broad spectrum um sunscreens. And then as I had mentioned, annual surveillance with a dermatologist in the interest of time, I just wanted to bring in the numerical data. This is for the non melanoma skin cancers. And if you look at the di appearing you will see that there was an increased odds ratio for that non melanoma skin cancer with that great with that class of medication and then brought in a visual for you as well. The blue, the dark blue bars being our non IBD patients and then the lighter ones being our ulcerative colitis or Crohn's disease patients staying here for the melanoma risk and IBD. If we go down to the biologic growth, you'll see an IBD overall Crohn's disease and ulcerative colitis that numerically there is an increased risk for those patients. And again a visual with the blue bar being the non IBT and the lighter one being our I. D. I. D. Patients. Colorectal cancer screening, we're all familiar that this is important in our inflammatory bowel disease patients. So in all sort of colitis when the extent is greater than the rectum screening and subsequent colonoscopy should be completed every three years with restaging biopsies. eight years after diagnosis when dysplasia and ulcerative colitis is not respectable. Or as multifocal patients should be referred for practical ectomy. And thus far there has been no medical therapy that has demonstrated sufficient to prevent dysplasia of colorectal cancer and thus we cannot avoid colonoscopy. Are screening? Okay, in chronic disease involving the colon, the risk of colorectal cancer is probably comparable to that of all sort of colitis. However not all studies have reached these conclusions and thus the magnitude of risk in these patients with chronic disease remains unsettled. And I did want to take a moment here to specifically mention this unique subset of patients which is I. B. D. With a dual disease state called overlapping with PSC or primary sclerosing cholangitis which is a liver disease that we often see in our IBD patients? Um Patients with this overlap disease state. Do you have a 10-fold greater risk of developing a column cancer and that's independent of what you find on your colonoscopy screenings. These patients should have yearly colonoscopies. And last lastly I'm going to speak a bit about depression, anxiety and smoking cessation together. Yeah many patients with I. B. D. Up to 10 to 35% suffer from anxiety, depression secondary to their disease and clearly need to be screened. I find this is very important. Especially nowadays when the mental health stigma that used to exist clearly is being broken and there are less barriers to that access to health care And you know after hearing everyone give their presentations today it's clear that there can be very devastating complications to these diseases. And getting that adequate mental health care is so important to their overall health and recovery. Yeah smoking in inflammatory bowel disease, nicotine and are smoking byproducts made defect may directly affect mucosal immune responses, smooth muscle tone, gut permeability and micro vasculature. While smoking is a direct risk factor to those with Crohn's disease it seems to have a peculiar protective mechanism to those with all sort of colitis. However, smoking cessation has countless benefits beyond diabetes and thus should be counseled for all of our patients. Um I might have gone through that a bit quickly but in the aspect of time perhaps that was good. So thank you very much
