Northeast Florida Medicine Journal, Winter 2015

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DCMS online. org Northeast Florida Medicine Vol. 66, No. 4 2015 37
Inflammatory Bowel Disease
Introduction
Inflammatory bowel disease (IBD) is a disorder involving
the GI tract and it typically comprises of two major dis-
orders: Crohn’s disease (CD) and ulcerative colitis (UC).
The pathogenesis for these disorders is poorly understood
despite the distinct characteristics. Crohn’s disease involves
the entire GI tract from mouth to perianal area and is
characterized by transmural inflammation with strictures
and fistulization. Ulcerative colitis involves the rectum and
extends into proximal colon in a continuous fashion. In
2007, the prevalence for CD was 201 per 100,000 and the
prevalence for UC was 238 per 100,000.1
Medical treatment for Inflammatory Bowel Disease
has been evolving rapidly and primarily takes the form
of immunosuppression. The treatment ranges from mild
topical treatment, such as mesalamine and budesonide, to
systemic steroids (prednisone). For more severe cases, as
well as for steroid sparing treatment, physicians have been
using immunomodulators (azathioprine andmethotrexate),
as well as biologic agents (infliximab, adalimumab, certoli-
zumab, golimumab, natalizumab, vedolizumab). Also, in
selected cases, transplant-type immunosuppression such
as tacrolimus, cyclosporine and mycophenolate are used in
treatment of IBD.
Immunization in IBD patients:
Immunization has been well recognized in the world of
solid organ and hematopoietic transplant, cancer patients
receiving chemotherapy and patients with HIV/AIDS. In
2013, international infectious disease specialists prepared an
updated guideline for vaccination of immunocompromised
adults and children.2 However, physicians are not doing
too well in terms of immunization of patients with IBD.
In 2008, a study looked at 116 IBD patients versus 100
control patients. The rate of screening for immunization
was lower in IBD patients (75 percent vs 84 percent).3
Prior to this, there was a study in 2006 that surveyed 169
IBD patients, with 145 patients reported being on current
or previous history of immunosuppression.4 In this group,
only 28 percent recalled having annual influenza vaccine,
9 percent recalled having pneumococcal vaccine and 45
percent recalled having tetanus vaccine in the past 10 years.
In addition, only 31 percent of the 75 patients who were
identified at risk for hepatitis B were vaccinated against
hepatitis B.4
Physicians also must decide which patients require vac-
cination. In 2011, Wasan’s group randomly sent out survey
to 1,000 members of American College of Gastroenterology
(ACG) regarding vaccination in IBD patients.5 Only 108
members (11 percent) returned the survey and only half
of the gastroenterologists reported asking about immuni-
zation history routinely. Seven percent reported that they
never ask their IBD patients about their immunizations.5
Of these returned surveys, 64 percent of the gastroenter-
ologists thought that the primary care providers should be
determining which vaccines to give and 83 percent thought
primary care providers should be giving the vaccines to the
IBD patients.
Definition of immunocompromised hosts:
There is a consensus by experts in term of who is defined
as immunosuppressed in the IBDpopulation. IBDpatients
who are considered to be immunosuppressed are patients
using corticosteroid at >20mg/day for more than two weeks
or within threemonths of stopping; patients on azathioprine
or 6-mercaptopurine or who have recently discontinued
within three months; patients on methotrexate or who
Vaccination Recommendations for Patients
with Inflammatory Bowel Disease
By Anhtung Chau, MD
Address correspondence to:
Anhtung Chau, MD
4800 Belfort Road
Jacksonville, FL 32256
(904) 398-7205
Abstract: Inflammatory bowel disease (IBD) is a disorder involving
the GI tract with poorly understood pathogenesis. Medical treatment
for IBD has been evolving rapidly, but mostly comprises of immuno-
suppression similar to transplant-type medications. Immunization is
safe and potentially life-saving, if done appropriately. It is important
for clinicians to know the schedule and recommendations in order
to vaccinate patients with IBD early if anticipating escalation of
immunosuppressive therapy.