Immunomodulators and biologic agents have revolutionized the care of people with inflammatory bowel disease (IBD), which includes ulcerative colitis and Crohn's disease. But there is a downside to these paradigm-shifting drugs: People who use them are considered immunocompromised, and are vulnerable to a variety of opportunistic and potentially severe infections.
Opportunistic infections such as pneumonia occur more frequently and are more severe in people with weakened immune systems. These and other infections are preventable by vaccinations given routinely by primary care clinicians. However, people with IBD often see only doctors who are part of their gastroenterology team, and tend to receive less routine preventive care than people in the general population.
Too few vaccinations
It has been well documented that routine vaccination among people with IBD is subpar. In one study, less than a third of patients seen at an IBD center reported getting a regular flu shot, and less than 10 percent had been vaccinated against pneumonia. Some reasons given for the low vaccination rates are patients’ fear of side effects and a lack of awareness.
Communication can be poor between primary care doctors and gastroenterologists. One survey of gastroenterologists found that most respondents thought primary care physicians should keep track of IBD patients’ vaccinations. Conversely, a survey of primary care physicians found that only 30 percent of them were comfortable managing vaccinations in their patients who have IBD.
Vaccinations should be given once the diagnosis of IBD has been made, regardless of the severity of disease. It is also critical to be tested for exposure to tuberculosis and hepatitis B before initiating biologic therapy, especially with anti-tumor necrosis factor (TNF) drugs. IBD patients who are cared for solely by gastroenterologists may not be receiving all the necessary preventive services that they should, including vaccinations and other services that are usually provided by primary care physicians, such as screening for depression.
The safety question
While concerns have emerged about vaccines increasing disease activity in people with IBD, there is no evidence to suggest that this is true. Vaccinations are generally well tolerated with few side effects or adverse reactions.
Basically, vaccines known as inactivated recombinant—as opposed to those that are live-attenuated—are considered safe for people with IBD regardless of their level of immunosuppression. Live-attenuated vaccines contain a weakened rather than a completely inactivated strain of the virus.
Note that vaccinations tend not to be as effective in patients who are on immunosuppressive therapy, so ideally, vaccines should be administered one to three months before immunotherapy is started.
People with IBD, as well as their family members, should get inactivated influenza, not the live-attenuated inhaled influenza vaccine.
Some live vaccines, such as varicella (chicken pox), can be given to people who are considered low-level immunosuppressed and who have stopped taking medication for three months and will not resume for six weeks. These medications include daily systemic corticosteroids, such as more than 20 mg of prednisone, and effective doses of methotrexate, azathioprine, or 6-mercaptopurine.
Live-attenuated vaccines are not recommended for people on anti-TNF medications, which is considered high-level immunosuppression. These include the newer biologics—vedolizumab (Entyvio), ustekinumab (Stelara), and tofacitinib (Xeljanz).
At least one month prior to starting immunotherapy, however, several live-attenuated vaccines—such as those that protect against measles/mumps/rubella (MMR), varicella, and herpes zoster—are recommended for all people with IBD who are not immune to or have not already been vaccinated against these diseases.
Of note, the FDA recently approved an inactivated recombinant herpes zoster vaccine for adults who are not immunocompromised, a two-dose vaccine known as RZV (Shingrix). The vaccine was not tested in immunocompromised individuals, but because it is not a live-attenuated vaccine, Shingrix can be administered to people on high-level immunosuppression medication if they have been previously vaccinated. It is recommended for adults with IBD over age 50.
Talk with your doctor before traveling to an area where yellow fever occurs. The vaccine for yellow fever is live-attenuated and generally should be avoided by immunocompromised individuals.
Essential Vaccines for Living with IBD
In addition to the inactivated vaccines listed in this chart, talk with your doctor about the timing for immunization with live vaccines for measles, mumps, and rubella (MMR) and chicken pox (varicella), which you may also require.
Preventive screenings: don’t miss them
People with IBD tend to be at higher risk for certain health-related problems because of either their disease or the medications they are taking. Screening and sometimes management for these conditions again often falls into the category of preventive care. If you haven’t already done so, discuss the following with your primary care doctor or an appropriate specialist:
- Smoking cessation. Smoking can increase disease activity in people with Crohn’s disease, and your doctor can suggest ways for you to quit.
- Colorectal cancer screening. Your gastroenterologist will advise you about the appropriate timing for colonoscopy, depending upon your condition and family history.
- Blood pressure screening. Use of corticosteroids can cause hypertension in people with IBD, so blood pressure should be checked at every visit.
- Gynecological screening. Women with IBD are at higher risk for cervical cancer than women in the general population, and should have a cervical cancer screening (Pap test) or an HPV (human papillomavirus) test, or both, perhaps more frequently than every three years, especially if they are on immunosuppressive therapy.
- Skin screening. There is a slight increased risk of melanoma with anti-TNF medication, and of non-melanoma skin cancers with current or past use of thiopurines such as azathioprine (Imuran), mercaptopurine (Purinethol), and thioguanine (6-TG, Tabloid, Lanvis). People with IBD who take these drugs should use sunscreen and receive regular skin screenings.
- Psychological screening. People with IBD tend to experience higher rates of both anxiety and depression than the general population, and should undergo screening at each visit with a discussion of treatment options if appropriate.
- Osteoporosis screening. Certain people with IBD may be at risk for osteoporosis. Some research supports obtaining a baseline bone mineral density (BMD) assessment so that BMD can be evaluated over time. Keeping serum vitamin D levels above 30 ng/ml is desirable.
You may consider your gastroenterologist your main health care provider, but health maintenance in people with IBD is complex and requires a multidisciplinary approach. It may be worth having a talk with your gastroenterologist to discuss how he or she is co-managing your care with your primary care doctor to ensure that everyone involved is up to date on your preventive care needs.
Published August 14, 2019