Preventative Healthcare Maintenance in IBD: Addressing Clinical Practice Gaps in the United States

Cancer Screening

Colon Cancer

Chronic intestinal inflammation is a primary risk factor for the development of gastrointestinal malignancy. All IBD patients with disease affecting the colon or rectum should have a colonoscopy 8-10 years after disease onset (symptoms) to evaluate for disease extension and to determine timing of future colon cancer surveillance [37-40 ]. Colon cancer surveillance intervals will vary based on risk factors. Risk factors for colorectal cancer includes disease duration, extent of disease, active disease, primary sclerosing cholangitis (PSC), family history of colorectal cancer, and pseudopolyposis [41-42]. For IBD patients with concurrent PSC, colon cancer screening should be started at diagnosis and annually there after [37, 40] If a patient has isolated ileal Crohn’s disease, then they are at similar risk of colorectal cancer to the general population [43]. Of note, small bowel Crohn’s disease does carry an increased risk of small bowel adenocarcinoma in areas of high inflammation, but routine surveillance is not recommended for small bowel cancer [44-45]. Colonoscopy is the only recommended modality for CRC surveillance. Patients should ideally have quiescent disease as inflammation can obscure precancerous findings. Lavage and careful inspection are key. Dye spray chromoendoscopy (DCE) versus virtual chromoendoscopy (VCE) can be used.  A metanalysis of 11 RCTs found that VCE was comparable to DCE and HD-WLE for dysplasia detection [43]. Universal nomenclature, updated terminology of polyp classification and scoring systems should be used on colonoscopy reports. The AGA Clinical Practice Update on Colorectal Neoplasia and recent BSG guidelines on colorectal surveillance in inflammatory bowel disease gives guidance on the management of visible and invisible dysplasia [40,43].

Anal Cancer

Although the absolute risk of anal cancer is low, it is higher than the general population [46]. The majority of anal cancers are due to squamous cell carcinoma. IBD patients with perianal disease, anal stricture, smoking, HPV infection, cervical dysplasia, HIV or ano-receptive intercourse are at an increased risk of anal cancer. Fistula-related adenocarcinoma develops in patients with longstanding perianal disease and may present with non-specific symptoms.

It is therefore imperative to ask about bleeding, pain, itching and potential lesions near the anal canal [47] Even though there are no recommended surveillance strategies, the anal canal should be inspected closely during colonoscopy, during digital rectal exam, upon retroflexion and withdrawal of the endoscope [45,48]. If an anal stricture is detected, this should be biopsied either on endoscopy or during exam under anesthesia with colorectal surgery. Internal openings of fistulas should be biopsied [47].

Skin Cancer

All patients with IBD have an increased risk of nonmelanoma skin cancers and therefore primary prevention with avoidance of excessive sun exposure and use of sunscreen is emphasized [32].  Patients on immunomodulators, anti-tumor necrosis factor inhibitors and small molecules should be referred to a dermatologist if available or to a primary care physician to have yearly total body skin exams due to increase risk in skin cancers (both melanoma and non-melanoma skin cancer) [49]. Thiopurine use, even after discontinuation, increases the skin’s photosensitivity to UVA light [50]. Therefore, any patient that has been on Thiopurines should have a yearly total body skin exam by dermatology despite discontinuation [49-50]. This risk appears to be dose and duration dependent; further studies are needed to evaluate the effects of short-term Thiopurine use. 

Cervical Cancer

There is conflicting data regarding increased risk of cervical dysplasia in women with IBD. There are select studies that suggest increased risk associated with immunosuppressive therapy [51]. However, data is insufficient to determine whether individuals receiving combined immunosuppression or thiopurines require more frequent screening. There is an increased risk of dysplasia with cigarette smoking. The AGA Best Practice Advisory follows USPSTF general population recommendations for ages 21 to 29 to be screened every 3 years with cervical cytology and ages 30 to 65 with cervical cytology every 3 years, HPV testing every 5 years or co-testing every 5 years [32,52]. These guidelines do not apply to those women with history of cervical dysplasia. Ultimately, shared decision making and individual risk stratification should be encouraged.

Psychologic Impact

Depression and anxiety rates are higher in individuals with IBD compared with their age-matched counterparts [53-54]. Depression and anxiety were strongly associated with surgical history, disease complications including extraintestinal manifestations, smoking and female gender. IBD patients with mental health conditions incurred significantly greater costs compared with IBD patients without mental health conditions signaling an importance of identifying and treating these conditions [55-57]. Mental health screening should be implemented early in the care of IBD patients. PHQ2 and GAD7 scales can be used for depression and anxiety screening, respectively. Although implementing a psychiatrist and psychologist in your practice can be helpful; there are resources globally as listed but not limited to this list (Table 3).

conditions

Table 3: List of Mental Health Resources Available in the US.

Bone Health

The prevalence of osteoporosis in IBD patients is as high as 42%. Patients with low BMI, steroid use, cigarette smoking, postmenopausal women, men > 65 years old, patients with chronic inflammation, vitamin D deficiency, or those with malabsorption should undergo bone density screening. It is imperative to screen for bone loss as supplementation and treatment can reverse osteopenia and osteoporosis and prevent factures [32,58]. If DEXA is normal, then it should be repeated in 5 years or in 2-3 years in the setting of increased risk factors. If the patient has osteopenia, supplemental calcium (1000 mg/day) and Vitamin D (800 IU/day) along with weight bearing exercises to improve bone mineral density should be advised. Monitoring with DEXA should be done in 2-3 years [59]. If osteoporosis is present, then referral to endocrinology or primary care is recommended for further management.

Eye Health

Approximately 10-43% of IBD patients develop eye problems. Ophthalmologic issues among IBD patients include uveitis, episcleritis or keratopathy [60]. Additionally, patients can have glucocorticoid induced cataracts or glaucoma [61]. Malabsorption and Vitamin A deficiency can increase ocular surface disease or lead to keratoconjunctivitis sicca [62]. It is recommended that patients undergo ophthalmologic evaluation annually [60]. The immediate cost-effectiveness of routine ophthalmologic exams require further research although screening can prevent potential severe complications [62]. Annual exams could be tailored to those individuals that are at high risk for ophthalmologic conditions including those who have malabsorption or have been on longterm steroids.

Malnutrition and Vitamin Deficiencies

Malnutrition in IBD can arise from a range of underlying factors, including anorexia, trigger avoidance, medication effects, drugnutrient interaction, malabsorption, inadequate intake, reduced caloric intake, active inflammation, altered anatomy due to prior surgery or short bowel syndrome [63-64]. Without adequate nutrition the immune system may not have the components needed to create an effective immune response resulting in suboptimal responses to vaccinations and an increase risk of infections [64].

Obesity has increased among IBD patients with epidemiologic studies suggesting that 15-40% of IBD patients are obese [65-70]. Obesity can impact medical therapy by decreasing drug-half life and trough levels as well as surgical management by increasing operative time and affecting perioperative complications [68,71]. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as a fundamental component in the management of diabetes and obesity; however their potential therapeutic role in IBD remains under investigation [72].

Vitamin and mineral deficiencies are prevalent in patients with IBD regardless of their body weight. Deficiencies can lead to clinically significant conditions such as anemia, osteoporosis and poor wound healing.  A case series, found 56% of IBD patients reported complete avoidance of fruits and vegetables [73]. It is suggested that those with active disease and in clinical remission should be routinely assessed for vitamin and mineral deficiencies.⁷⁴ There haven’t been formal guidelines to assess micronutrient deficiencies in the setting of IBD until the recent AGA clinical practice update and ECCO consensus on dietary management of IBD, both of which advise all patients with IBD to be monitored for Vitamin D, zinc and iron deficiency. Those with a prior ileal surgery or who follow a vegan diet, should be monitored for Vitamin B12 [75-76]. Vitamin C, known as the forgotten micronutrient, can also be decreased in IBD.⁷⁷ Screening for malnutrition and obesity and assessing dietary intake is critical.

Women’s Health

For women with IBD, it is important to provide education and implement screening plans for cervical cancer and bone health. The HPV vaccine is paramount in preventing cervical neoplasia in these at risk patients. The vaccine is approved for individuals between the ages 9 and 45 and can be provided by their internist or gynecologist [32].

Screening for bone health is pertinent to all IBD patients, but especially women with IBD. These individuals have an increased risk in developing osteoporosis due to post menopause estrogen changes, lower BMI, low vitamin D absorption, and possibly prior steroid use [78].

It is important to recognize that patients with IBD are not at a disadvantage compared to the general population in terms of fertility and opportunity to get pregnant if the patient is in disease remission. There are a couple of factors that may contribute to pregnancy complications such as active disease, prior surgical procedures to the abdomen such as a J pouch, or nutritional concerns that can lead to preterm labor, low birth weight, or miscarriage [79].

Conversations about planned pregnancies should be integrated into the visits for all women of childbearing age, especially before required changes to the treatment are made. This will allow ample time to adjust treatment, as well as update required vaccinations and assess vitamin deficiencies [80].

Advanced Age Population

The prevalence of IBD is rising in those older than 65, with a range of differential diagnoses masking as IBD that should be considered carefully during the diagnostic process [81]. Despite this rise, older IBD patients are under-represented in clinical trials for immunosuppressive therapies [82]. The management of older IBD patients remains variable, largely due to a lack of evidencebased guidelines tailored to this population, which in turn leads to a greater reliance on corticosteroids for long periods rather than escalating to advanced therapies [83-85]. However, prolonged use of corticosteroids in the elderly has been associated with a higher risk of serious adverse events [81, 86]. Treatment goals should be adjusted to the patients’ biological age with transmural healing taking a step back and allowing symptom control to be the most important aspect to consider.

Healthcare maintenance is important in this “older than traditional IBD patient population” as this group is vulnerable due to comorbidities and potential cognitive decline from aging [87]. Gastroenterologists and primary care physicians need to be vigilant in preventive screening for osteoporosis, ocular disease, depression and adverse events related to polypharmacy. When considering cancer screening guidelines, life expectancy, functional performance status, comorbidities, finances and the patients desires need to be at the forefront [88-89].

Mental health should be assessed if time allows with the gastroenterologist or with a primary care provider as anxiety and depression rates are higher in the older IBD population. Isolation, adequate housing, transportation and food insecurity due to potential fixed income should be a routine discussion with a primary care physician, geriatrician or social worker [90-91].

Elderly individuals with IBD are at a high risk for bone loss and osteoporosis due to factors like chronic inflammation, nutritional deficiencies and medications. Old age was associated with the highest risk for fracture-related hospitalizations in IBD patients. Other risk factors for osteoporosis in IBD include low body mass index, immobilization or sedentary lifestyle, previous fragility fracture, smoking, excess alcohol consumption, malnutrition, malabsorption, calcium and Vitamin D deficiency. Patients should be monitored for decreased bone mineral density [92].

Implementing Healthcare Maintenance

Understanding the complexities of healthcare maintenance is important but implementing preventive care is imperative to achieve improved patient outcomes within the U.S. Healthcare system. Despite the availability of established guidelines, preventive health measures remain underutilized in patients with IBD, with gaps in vaccination delivery, cancer screening, infection screening, and bone health assessment, which often contribute to a greater burden of disease to the patient, provider and healthcare system. One barrier is the disconnect between gastroenterologists and the primary care physician (PCP), as there can be an uncertainty regarding the responsibility for preventive health maintenance. The first step in addressing these gaps is to actively promote collaboration between gastroenterologists and PCP with patient engagement [93]. Studies have shown that involving patients in their care leads to improved health outcomes [94]. Prasad et al proposes IBD educator roles, similar to a diabetes educator, to improve knowledge and access of preventive care among patients to empower them to understand their health and bridge gaps [95]. A similar concept proposed by Singh et al, looks at the development of IBD counsellors to bridge the gap between doctors and patients. This is particularly important in the U.S. as this can allow for psychosocial support, lifestyle and dietary guidance while being culturally aware to sociocultural norms, improving overall health [96].

Dissemination of current U.S. based preventive care recommendations, including those from ACIP, USPSTF, AGA, with direct referrals to primary care, gynecology, ophthalmology and dermatology can improve communication and quality of IBD care. Evidence from a multicenter quality improvement initiative conducted across 27 U.S gastroenterology practices showed that having standardized care with preventive care strategies and monitoring improved provider communication, significantly reducing emergency department visits and hospitalizations among IBD patients [16].

The IBD medical home is a concept that encompasses a team of physicians, social workers, dieticians and nurses to monitor IBD patients for psychosocial issues and flare symptoms [97]. The medical home can also be used to reinforce preventive care guidelines by administering vaccines [98]. One study found the implementation of vaccines in the gastroenterology clinic resulted in an increased vaccination rate among IBD patients [99]. Vaccines can be administered during periods of remission at routine visits, nurse visits or even by sending the vaccine to the patient’s preferred pharmacy. In the U.S., this approach can be further expanded to collaborate with primary care and gastroenterology practices, and through local pharmacies.

Brunt et al furthered the idea of an IBD specialty home by proposing an IBD primary care physician; a condition-focused internist to treat comorbid conditions in the setting of IBD which not only can improve outcomes but reduce costs. The IBD primary care physician can function as a primary care provider in addition to one that understands the complexities of IBD and can manage the other issues that may arise including extra-intestinal manifestations and chronic fatigue [100]. This role is especially important within the U.S Healthcare system where there is an increase in disease complexity with PCP shortage. These providers can tackle healthcare maintenance by delivering vaccinations in a timely manner, evaluating bone density, collaborating with behavior health and/or psychological services to address mental health and refer to specialists (ophthalmologists, gynecologists, dermatologists) when needed. The “IBD Medical Home” was implemented by University of Pittsburgh Medical Center, which resulted in 47.3% fewer emergency visits, 35.9% hospitalizations resulting in $2,500 savings per patient per year [101]. This multidisciplinary care model, as demonstrated in Figure 1, highlights the potential benefits of coordinated preventive care strategies in improving outcomes, while reducing healthcare costs for patients with IBD in the United States.

Conclusion

The progressive and chronic nature of IBD places the gastroenterologist in a unique patient-provider relationship due to the close monitoring and frequency of appointments. The gastroenterologist needs to understand the intricacies of advanced therapy and the vaccine recommendations that are different from non-IBD patients. Healthcare in IBD patients encompasses more than vaccines as discussed in this review. It is imperative that the gastroenterologist stay up to date on these recommendations to provide comprehensive care. There can be challenges to ensure all aspects of the patient’s health are addressed. Referral pathways, implementation of an IBD medical home or IBD counsellors may be a future option to provide integrated care.

Acknowledgements

None

Funding

None

Conflict of Interest

Pranaya Pakala – none

Katherine Westbrook Cates – none

Ann Porter Uhlhorn - Honorary speaker for AbbVie, Johnson and Johnson

Nisha Loganantharaj – Honorary speaker for AbbVie, Johnson and Johnson and Takeda

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