Faculty

Gary R. Lichtenstein, MD Louis Kuritzky, MD

Director, Inflammatory Bowel Assistant Professor
Disease Center Emeritus
Professor of Medicine Family Medicine
Hospital of the University of Residency Program
Pennsylvania University of Florida
Philadelphia, PA Community Health &
Family Medicine
Gainesville, FL
 Disclosures
Gary R. Lichtenstein, MD
Consulting for: Abbvie, Actavis, Alaven, Celgene, Ferring, Hospira,
Ironwood Pharmaceuticals, Janssen Orthobiotech, Luitpold
Pharmaceuticals, Merck, Pfizer, Prometheus Laboratories, Inc.,
Romark, Valeant, Shire Pharmaceuticals, Takeda, UCB

Louis Kuritzky, MD
Has no relevant financial relationships to disclose.
 Learning Objectives

Apply evidence-based testing and tools to

diagnose IBD in primary care practice

Discuss efficacy and safety of conventional

and biologic therapies for IBD

Develop a health maintenance plan for a

patient with IBD

IBD, inflammatory bowel disease.

WHY SHOULD PRIMARY CARE CLINICIANS
BE CONCERNED ABOUT IBD?

Louis Kuritzky, MD
 Scope of IBD in USA
Estimated prevalence1
• UC: 37-346:100,000
• CD: 26-199:100,000

Physician visits: >700,000/year2

Hospitalizations: 100,000/year2

Annual direct costs: ~$4 billion3

1. Lichtenstein G. 2012. Goldman's Cecil Medicine. 24th ed. . Philadelphia, PA: Elsevier Saunders; 2012:913-921.
2. CDC. http://www.cdc.gov/ibd/. 2015.
3. Lichtenstein GR. Am J Gastroenterol. 2016.[Abstract 682]
 Clinical Consequences
of Delayed IBD Diagnosis
Poor quality of life
Early referral to GI is
Relapse rates important for
effective treatment
Increased cancer risk

Infection risk Delayed diagnosis

Anemia ↓
Delayed treatment
CD: Progressive disease w/strictures
↓
CD: penetrating disease Worse outcomes
GI, gastrointestinal.
Anderson NN, et al. JAMA. 2014;311:2406-2413.
Kotlyar D, et al. Gastroenterol. 2015; 13:847-858.
Lichtenstein GR, et al. Am J Gastroenterol. 2012;107:1409-1422.
 What is the Role of
Primary Care Clinicians in IBD?
• IBD patients do not receive preventive services at the same rate as general
medical patients
• Immunosuppressive and biological agents are being used earlier and for
longer in the course of disease
– Potential to increase the risk of opportunistic and serious infections in
IBD patients
IBD-Related Health Issues Addressed by Primary Care Clinicians

Monitoring IBD-related complications Pap smears

Osteoporosis Smoking cessation
Iron deficiency Dermatological evaluation
Cardiovascular disease Psychosocial factors
Cancer Sexual/reproductive health
Vaccination Medication adherence
Monitoring laboratory studies Recognition of IBD relapse and/or acute severe colitis

Sinclair JA, et al. Gastroentergology. 2012;41(2):325-337.

Bennett A, et al. World J Gastroenterol. 2015;21(15):4457-4465.
Gikas A. Int J Gen med. 2014;7:159-173
 The Role of
Primary Care Clinicians in IBD

Initial recognition of signs +

symptoms that warrant specialist
investigation and diagnostic
evaluation

Ongoing health maintenance for

the IBD patient
IDENTIFYING IBD IN PRIMARY CARE

Louis Kuritzky, MD
Etiologic Theories in Inflammatory Bowel
Disease

Mucosal Immune System

Genetic (Immuno-Regulatory
predisposition Defect)
IBD

Environmental Triggers
(luminal bacteria,
infection, NSAIDs,
smoking)
Clinical Features
of Ulcerative
Colitis
Colon only

Rectal involvement

Mucosal disease

Diffuse ulceration, granularity,

friability, bleeding, exudate

No fistulas or granulomas

Non-smokers

No prior appendectomy
Symptomatology of Ulcerative Colitis
 Altered bowel movements
- Increased stool frequency
- Decreased stool consistency
 Abdominal pain
- LLQ cramping, relieved with
defecation
- Tenesmus
 Blood in stool
Clinical Features of Crohn’s Disease
Any segment

Rectal sparing

Skip lesions

Transmural

Aphthous ulcers, serpiginous

ulcers, cobblestoning

Fistulae

Granulomas

Smokers
Crohn’s Disease Symptomatology

Chronic or nocturnal diarrhea and abdominal pain

Postprandial RLQ abdominal pain, distension
Weight loss
Fever
Rectal bleeding

RLQ, right lower quadrant

Lichtenstein GR et al. Am J Gastroenterol 2009;104:465-83; quiz 464, 484.

 Extraintestinal Manifestations of IBD
Peripheral arthritis
Joints Ankylosing spondylitis and
sacroiliitis

Kidney stones
Pyoderma gangrenosum
Interstitial Renal Skin Erythema nodosum
nephritis

Venous Episcleritis
Hypercoagula
thrombosi ble state
Eyes Uveitis
s Cataracts

Hepatobili
ary Sclerosing
cholangitis
Gallstones
Levine JS, et al. Gastroenterol Hepatol (N Y). 2011;7(4):235-241.
 Components of IBD Diagnosis
• History
• Physical Examination
• Labs
– CBC, CMP, ESR, CRP, iron studies,
Endoscopy vitamin B12
• Fecal calprotectin or lactoferrin
Histology • Stool
– C difficile toxin, culture, ova &
parasites
• Colonoscopy
Radiography • EGD if CD suspected
– Wireless capsule endoscopy of small
intestine
Clinical course of symptoms – CT and MRI enterography
– Barium small bowel follow through
– Device assisted balloon enteroscopy

CBC, complete blood count; CMP, comprehensive metabolic panel; CRP, C-reactive protein;
EGD = esophagogastroduodenoscopy; ESR, erythrocyte sedimentation rate; CT, computed tomography; MRI, magnetic
resonance imaging.
Mill J, Lawrence IC. WJG. 2014;20(29):9691-9698.
Kornbluth A, et al. Am J Gastroenterology. 2010;105(3):501-523.
CURRENT TREATMENT OVERVIEW

Gary R. Lichtenstein, MD
 Treatment Goals
Induce clinical remission (absence of symptoms)

Avoid short- and long-term toxicity of treatment

Enhance quality of life

Maintain steroid-free remission

• Avoid repeated courses of steroids!

Induce “deep” remission

• Biologic remission (normalization of biomarkers)
• Mucosal healing

Prevent complications (hospitalizations, surgery, etc)

Reduce cancer risk

Reenaers C, et al. World J Gastroenterol. 2012;18(29):3823-3827

Hommes D, et al. J Crohns Colitis. 2012;6(Suppl 2):S224-S234.
Progression of Digestive Disease Damage
and Inflammatory Activity

Stricture

Inflammatory Activity
Surgery

(CDAI, CDEIS, CRP)

Digestive Damage

Fistula/abscess

Stricture

Disease Diagnosis Early

onset disease

Pre-clinical Clinical

Pariente B et al. Inflamm Bowel Dis 2011;17(6):1415-22

CDAI: Crohn's Disease Activity Index; CDEIS : Crohn’s Disease Endoscopic
Index of Severity; CRP: C-Reactive Protein
 Risk Factors for a More Severe
Disease Course
Crohn’s Disease Ulcerative Colitis
 Early age at diagnosis (<40)  Early age at diagnosis (<40)
 Perianal involvement  Early steroid treatment
 Severe deep ulcerations on  Extensive colitis
endoscopy  Hospitalization @ diagnosis
 Multiple areas of bowel
involvement  Elevated inflammatory
 Current tobacco use markers
- CRP, ESR
 Other
- Prior resections
 Low serum albumin
- Stricturing or penetrating
disease
- Early steroid treatment
Peyrin-Biroulet L, et al. Clin Gastroenterol Hepatol. 2016;14(3):348-354.
 Treatment Paradigm Shift:
Decision-Making in IBD

OLD = treat based on NEW = treat based on

symptoms objective markers of
• But symptoms are insensitive and inflammation
nonspecific for bowel • Serologic (CRP reduction)
inflammation • Endoscopic (mucosal healing)
• Radiographic (CTE/MRI
improvement)
Conventional Approach to Induction Therapy:
Step Up
Disease Severity
at Presentation Investigational agent/
Surgery

Anti-TNF +/-IS Anti-TNF/Anti-Integrin

Severe Anti-Integrin +/- IS

Systemic Thiopurine/
Moderate Corticosteroid MTX

Budesonide Budesonide
Mild Induction
Maintenance

 Therapy is stepped up according to severity at presentation or failure at prior step

 Clinical approach to use “mildest” form of drug therapy to treat patients first
 Move to next step in non-responders
 Step Up Management

Advantages Disadvantages
 Patients attain remission with
 Patients have to ‘earn’ most
less toxic therapy
 Potentially more toxic effective treatments
↓ QoL before patients
therapies reserved for severe
obtain optimal therapy
or refractory disease  High likelihood of surgery
 Minimizes risk of adverse
 Disease is not modified
events
 Cost-sparing (short-term?)
New Paradigm: Treating Beyond Symptoms
Early
“Top-Down Approach”

IMs + TNF
Severe antagonist
Anti-TNF Agents UC CD
Infliximab + +
Adalimumab + +
TNF antagonist
+/- IMs Golimumab +
Certolizumab +
Corticosteroids
Moderate +/- IMs Pegol +
Anti-integin Agents
Corticosteroids
Vedolizumab + +

Conventional Natalizumab +
”Bottom-Up Approach”

IMs, immunosuppressant; UC, ulcerative colitis; CD, Crohn’s disease.

D'Haens GR. Nat Rev Gastroenterol Hepatol. 2010 Feb;7(2):86-92.
Terdiman JP, et al. Gastroenterology. 2013 Dec;145(6):1459-63.
Sandborn WJ, et al. J Crohns Colitis. 2014;8(9):927-935. Amezaga AJ, et al. Curr Gastroenterol Rep. 2016 Jul. 18 (7):35.
 Evolving Treatment Approach in UC
Current Approach Emerging Approach
 Newer therapies w/favorable
 Assessment of prognosis
safety + side-effect profiles
 Optimization of AZA/6-MP
 Individualized therapy based
dose or metabolites
on genetics + physiology
 Earlier adoption of biologic
 Treatment to hard endpoints
therapy when appropriate  e.g. mucosal healing or
 Appreciation for the its surrogates)
implications of mucosal  Disease monitoring to
healing
prevent relapse
Current Medications for Active Disease
 5-Aminosalicylic acid  Immunomodulator agents
- azathioprine, 6-mercaptopurine,
derivatives
methotrexate, cyclosporine
- sulfasalazine, mesalamine,
 Tumor necrosis factor inhibitors
balsalazide, olsalazine
- Infliximab
 Antibiotics - Adalimumab
- metronidazole, ciprofloxacin, - certolizumab pegol
rifaximin - golimumab
 Corticosteroid agents  Anti-integrin agents
- hydrocortisone, prednisone, - natalizumab
- vedolizumab
methylprednisolone,
 Anti-IL-12/23 agents
prednisolone, budesonide,
- Ustekinumab
dexamethasone
Current Medical Therapies for
Symptomatic Relief

Antidiarrheal agents
• diphenoxylate and atropine, loperamide,
cholestyramine

Anticholinergic antispasmodic agents

• dicyclomine, hyoscyamine
Serious Side Effects of Prolonged GCS
Therapy
Hypertension <20%
Diabetes 2.33 relative risk for beginning insulin
Infection 13-20%
Osteoporosis <50%
Myopathy 7%
Cataracts 22% (dose-dependent)
Psychosis (3-5%)
*Overall GCS therapy (not only therapy for CD).

Sandborn W. Can J Gastroenterol. 2000;14(suppl C):17C-22C.

 Predictors of Serious Infection &
Death in CD
6273 patients in the TREAT registry; average follow-up: 5.2 years

Predictors of
Serious Infection HR Predictors of Death HR
Moderate to severe CD 2.24 Use of prednisone 2.14
Use of narcotic pain 1.98 Use of narcotic pain 1.79
relievers relievers
Use of prednisone 1.57
Use of IFX 1.43

Abbreviations: IFX, infliximab; HR, hazard ratio. P < .05 for all.

Lichtenstein GR, et al. Am J Gastroenterol. 2012;107(9):1409-1422.

 Safety and Toxicity
Mesalamine Considerations
5-ASA
1
AZA/6-MP 4
MTX5-6
Low incidence of Incidence of kidney Pancreatitis (4%) Nausea/vomiting
adverse effects impairment occurs in Allergy (2%) Bone marrow
 Diarrhea, less than 1 in 200 Bone marrow suppression
headache, nausea (<0.5%) patients suppression (4%) Liver scarring
most common treated with 5-ASA2 Liver toxicity (9%)
Serious infection (2%)
 Abdominal pain
 Dyspepsia
 Acute tolerance
syndrome Clinically important Increased risk of Contraindicated if
interstitial nephritis lymphoma attempting pregnancy
 Nephrotoxicity occurs in 1 in 500 Nonmelanoma skin
patients―50% of cases cancer
 Pancreatitis occur in the first year, Abnormal Pap smears
and others may occur
many years later3

1. Feagan BG, et al. Cochrane Database Syst Rev. 2012;10:CD000544. 2. Gisbert JP, et al. Inflamm Bowel Dis.
2007;13(5):629-638. 3. World MJ, et al. Nephrol Dial Transplant. 1996;11(4):614-621. 4. Kotlyar D, et al, Clinical
Gastroenterology and Hepatology. 2015;13:847–858. 5. Lichtenstein GR, et al. Am J Gastroenterol.
2009;104(2):465-483. 6. Methotrexate injection USP [package insert]. Lake Forest, IL: Hospira, Inc.; 2011.
 Anti-TNF Drug Safety
Infection and malignancy
• Black-box warning for serious infection and malignancy for all anti-TNF therapies 1-3

Black-box warning for HSTCL (ADA and IFX)1,2

Reactivation of hepatitis B4

Skin cancer4

Psoriasis4

Autoimmunity (lupus-like syndrome <1%)4

Immunogenicity―antibodies to anti-TNF4

Demyelinating disorders, CHF, liver toxicity4

CHF, congestive heart failure; 1. Remicade [package insert]. Horsham, PA: Janssen Biotech, Inc.; 2013.
2. Humira [package insert]. North Chicago, IL: AbbVie, Inc.; 2013.
HSTCL, hepatosplenic T-cell lymphoma
3. Simponi [package insert]. Horsham, PA: Janssen Biotech, Inc; 2013.
4. Bongartz T, et al. JAMA. 2006;295(19):2275-2285.
 Anti-Integrin Drug Safety
Should not be used in patients:

• With impaired immunity

• Taking immunosuppressants (i.e Natalizumab)
• Taking TNF inhibitors

Increased risk for progressive multifocal

leukoencephalopathy (PML)

Headache, fatigue, depression, rash, nausea, abdominal

discomfort, UTI, arthralgia, respiratory infection
 Ongoing Therapeutic Monitoring
Mesalamines
• Periodic kidney function w/urine + blood tests

Corticosteroids
• Bone health issues

Thiopurines
• TPMT, CBC, LFT during therapy

Methotrexate
• CBC, LFT, renal function during therapy, alcohol avoidance, pregnancy prevention

Anti-TNF
• Consider annual TB test
• Coccidiomycosis + histoplasmosis testing for patients living or who have lived in high
prevalence regions
Anti-Integrin
• Monitor for PML, LFTs, TB screening according to local practice, infection,
neurological symptoms
TPMT, thiopurine methyltransferase; CBC, complete blood count; LFT, liver function tests;
TB, tuberculosis; TNF, tumor necrosis factor.
EXTRAINTESTINAL MANIFESTATIONS
AND COMORBIDITIES

Louis Kuritzky, MD
Immune-Mediated Inflammatory Disorders

Bacteria Environmental factors

Genetics Others

Immunological alterations of
acquired + innate immunity

INFLAMMATION

Axial skeleton Kidney

Gut Eye
Peripheral joints Liver
Skin

Levine JS, Burakoff R. Gastroenterol Hepatol (N Y). 2011;7(4):235-241.

 Dermatological Manifestations
• Erythema nodosum:
• Most common skin
manifestation
• Crohn’s disease >ulcerative colitis
• Up to 5% of patients
• Usually parallels disease activity
• Extensor surfaces of the
extremities
 Skin Cancer
→ Sun protection
→ Dermatology screening
Levine JS, Burakoff R. Gastroenterol Hepatol. 2011;7(4):235-241
 Dermatological Manifestations
• Pyoderma gangrenosum:
• Ulcerative colitis ~2%,
Crohn’s disease ~5 % of
patients
• Destructive cutaneous lesion
• Most common site is the legs
• Independent of disease
activity in 50% of patients

• Other skin lesions:

• Psoriasis ~10% in Crohn’s
disease
• Sweet’s syndrome
• Metastatic Crohn’s disease

Levine JS, Burakoff R. Gastroenterol Hepatol. 2011;7(4):235-241

 Musculoskeletal Manifestations
• Peripheral arthritis:
• Occurs in 15% of patients
• Female:male ratio = 1:1
• Large joints,
nondeforming, nonerosive
• Spondylitis in 1-26%
• Male>female
• Sacroilitis:
• Frequency varies with
diagnostic modality:
• MRI pelvis Early diagnosis is key
• X-ray: 4-18%  Back pain + morning stiffness
 Symptoms unrelated to IBD activity
• Nuclear scan: up to 52%
Levine JS, Burakoff R. Gastroenterol Hepatol. 2011;7(4):235-241
 Assess Bone Mineral Density
BMD decreased by • e.g. steroids, methotrexate,
some medications cyclosporine

Osteoporosis/
osteopenia

• Repeat in 1 year if abnormal

Measure BMD/DEXA • 2 years if normal + no change in status
• 1 year if normal + change in status

Bisphosphonates,
calcium, vitamin D

www.ccfa.org
Bernstein CD, et al. Clin Gastro Hepo. 2006
 Ocular Manifestations
• Affects 43% of IBD patients
• Most commonly involve anterior chamber:
• Episcleritis: 2-5%
• Posterior chamber:
• Uveitis 0.5-3%
• Female:male ratio = 4:1
• Bilateral
• 75% have associated arthritis
• Requires immediate evaluation/emergency
• From steroid treatment:
• Cataracts
Annual screening
Felekis T, et al. Inflamm Bowel Dis. 2009. Levine JS, Burakoff R. Gastroenterol Hepatol. 2011;7(4):235-241
 Hypercoagulable State

• Thrombosis in IBD: 1.3-6.4%

• Mostly follows disease activity
• Multifactorial:
• Factor V Leiden deficiency
• Thrombocytosis
• Hyperhomocysteinemia
• Catheters

Owczarek D, et al. World J Gastroenterol. 2014;20(1):53-63.

 Hepatobiliary Complications
Primary sclerosing cholangitis:
• Occurs in 2% of ulcerative colitis patients
• 90% of primary sclerosing cholangitis patients have
ulcerative colitis
• Cholangiocarcinoma
Fatty liver
Effects of medications
Gallstones:
• ~33% of patients with ileal disease

Levine JS, Burakoff R. Gastroenterol Hepatol. 2011;7(4):235-241

 Aphthous Stomatitis
Most common oral lesion in IBD
Highly variable response to steroids and
antibiotics
Need to consider nutritional deficiencies
- Folate
- Zinc
- Vitamin B12
- Iron

Levine J. In: Kirsner JB, ed. Inflammatory Bowel Disease. 5th ed. 2000:397.
Su CG et al. Gastroenterol Clin North Am. 2002;31:307.
 Renal Manifestations in IBD
 Occur in 4% to 23% of  Obstructive uropathy
patients - Especially in CD, may occur
from intestinal inflammation
 Nephrolithiasis most pressing on ureter
common - Treatment is surgery
- Prevalence of 7% to 10%  Urinary tract fistulization
- Multifactorial causes - May present as
- Usually calcium oxalate stones pneumaturia, fecaluria,
 From hyperoxaluria or recurrent infection
 Treatment includes calcium - Successfully treated with
- Also uric acid stones immunomodulators,
 Treat as any other anti-TNF therapy
kidney stone
Su CG et al. Gastroenterol Clin North Am. 2002;31:307.
 Vaccinations, Cancer screening

HEALTH MAINTENANCE IN IBD

Louis Kuritzky, MD
Recommended Immunization Schedule for Adults
Aged 19 Years or Older, by Vaccine and Age Group
• Consider vaccinating ALL susceptible IBD patients at diagnosis before
immunosuppressed
• ”High-dose" flu vaccine available for people ≥65 years

Caution for
patients on anti-
TNF

Check Varicella UNLESS

on prednisone > 20 mg/day or
on immunosuppressives
(currently or recently Give to ALL patients
discontinued within 3 months (high, low or planned
immune suppression)
and once 5 years later

If non immune, then vaccinate.

If infected, treat prior to starting

anti-TNF medications

Kim DK, et al. Ann Intern Med. 2016;164(3):184-194.

 Will the Vaccinations Work in
Immunosuppressed IBD Patients?
 IBD patients receiving pneumovax, tetanus, influenza and HIB on
azathioprine/6MP monotherapy had a normal response to
vaccinations
 Adult
- IBD patients receiving pneumococcal vaccine had poor response if on
combination anti-TNF + immunomodulator therapy
 Pediatric
- IBD patients receiving influenza vaccine had a poor response if on
combination anti-TNF + immunomodulator therapy
 In patients with juvenile systemic lupus, main predictor of LACK
of response was a higher disease activity (not immune
suppression)

Lu Y, et al. Am J Gastroenterol 2009;104:444-53.

Melmed GY. Gastroenterol Hepatol. 2008;4(12):859-861
Campos LM, et al. Arthritis Care Res 2013;65:1121-1127
 Colorectal Cancer Risk in IBD

• Duration of disease >8 years

• Family history of colorectal
cancer increases risk
• Primary sclerosing cholangitis
(PSC)

Farraye FA, et al. Gastroenterology. 2010;138:746-774.e4.

 Cancer Surveillance
Screening colonoscopy 8-10
years after symptom onset to
detect dysplasia

Surveillance colonoscopy
every 1-3 years to detect
dysplasia with colectomy if
positive

CRC, colorectal.
Farraye FA, et al. Gastroenterology. 2010;138:746-774.e4.
American Society for Gastrointestinal Endoscopy and American Gastroenterological Association. GIE. 2015;81(3):489-
501
 Smoking Cessation

HEALTH MAINTENANCE IN IBD

Gary R Lichtenstein, MD
Cigarette Smoking and IBD: Meta-Analysis
Ulcerative Colitis Crohn’s Disease
• 13 studies, >11,000 patients • 9 studies, >10,000 patients
for UC for CD
• Current smoking is • Current smoking is
protective of development associated with CD
of UC – OR, 1.76 (95% CI, 1.40-2.22)
– OR, 0.58 (95% CI, 0.45-0.75) • Former smoking is weakly
• Quitting smoking is associated with CD
associated with UC – OR, 1.30 (0.97-1.76)
– OR, 1.79 (1.37-2.34)
Effects of cessation: 65%
lower risk of flare up vs
continuing Lower needs for
steroids + medications

Mahid SS, et al. Mayo Clin Proc. 2006;81(11):1462-1471.

Abbreviations: OR, odds ratio; CI, confidence interval.

 Effective Medications
for Smoking Cessation
Nicotine replacement products

Over-the-counter (nicotine patch [which is

also available by prescription], gum,
lozenge)

Prescription (nicotine patch, inhaler, nasal

spray)

Prescription non-nicotine medications:

bupropion SR,2 varenicline tartrate

Counseling and medication are both

effective for treating tobacco dependence,
and using them together is more effective
than using either one alone

SR, sustained release.

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm#methods
 Depression Screening
• Affects 15%-35% of IBD patients
– Relapsing nature of disease
– Chronic pain
– Steroids
• American College of Preventive Medicine/USPSTF
recommend screening

SCREENING QUESTIONS
1. Over the past month, have you felt down, depressed, or hopeless?
2. Over the past month, have you felt little interest or pleasure in doing things?

Siu AL, et al. JAMA. 2016;315(4):380-7

 Self-Management in IBD

Self-management is • Entails clear goals, understanding

critical to patient of the disease, plan of action to
improvement reduce symptoms or prevent
disease activity

Psychological issues,
shared decision • Depends on a good
making, and individual patient/clinician relationship
patient characteristics
should be discussed

Kennedy A, et al. Health Educ Res. 2005;20(5):567-578.

Bennett AL, et al. World J Gastroenterol. 2015;21(15):4457-4465.
SUMMARY
 Health Maintenance Summary
Vaccinations: influenza, pneumococcal pneumonia, zoster, Hep A, Hep B

DEXA Scan
• All CD and UC patients with conventional risk factor for abnormal BMD

Refer to GI to attempt corticosteroid withdrawal

• 6-MP / AZA, MTX, anti-TNF , Anti-integrin therapy Anti- IL – 12/23

A multivitamin daily; folate, calcium

Colon cancer surveillance

• After 8-10 years colonoscopy with biopsies [1-3 years] to assess for dysplasia

Annual Pap smears if immunocompromised

DEXA, dual-energy X-ray absorptiometry; GI, gastrointestinal; AZA, MTX, TNF

Health Maintenance Summary
Frequent dermatological evaluation: melanoma/NMSC

Beware of NSAIDs in IBD

• Disease may flare, bleeding may occur

Beware of other steroid side effects

•Cataracts, hypogonadism, osteonecrosis, etc.

Pregnancy
•Ensure that medications are safe + disease is in remission

Diagnosis
•In those with symptoms/signs, remember genetics
•When EIM present, think of disease

NMSC, non-melanoma skin cancer

NSAIDs, non-steroidal anti-inflammatory drugs; EIM, extraintestinal manifestations.