Varicella (Chicken Pox – Live Vaccine)
Check Varicella Zoster Virus IgG. If negative consider vaccination. Can be considered in patients on “low dose” immunosuppression (prednisone ≤
20mg/day, MTX, 6-MP, azathioprine), but not on biologics. Can administer > 4 weeks prior to starting biologics.
Herpes Zoster (Shingles – Non-Live Recombinant Vaccine (RZV))
Recommended for patients taking low-dose immunosuppressive therapy and persons anticipating immunosuppression. Recommendations regarding the use of RZV in patients already on higher does immunosuppression have not yet been made by the CDC.
MMR (Live Vaccine)
Contraindicated in immunosuppressed patients and those planning to start immunosuppressants within 4 weeks.
Diphtheria and Pertussis (Non-Live Vaccine)
Vaccinate with Tdap if not given within last ten years, or if Td ≥ 2 years.
Influenza (Non-Live Vaccine)
One dose annually to all patients during flu season. Avoid intranasal live vaccine in immunosuppressed patients.
HPV (Non-Live Vaccine)
Related to cervical and anal cancer. Three doses approved for females and males ages 9-26 (regardless of immunosuppression).
Hepatitis A (Non-Live Vaccine)
Safe to administer to at-risk patients regardless of immunosuppression.
Hepatitis B (Non-Live Vaccine)
Check hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody before initiating anti-TNF therapy. If non-immune consider vaccination series with non-live hepatitis B vaccine, 3 doses. If active viral
infection or core Ab positive, check PCR and withhold anti-TNF therapy until active infection is excluded or treated appropriately.
Meningococcal Meningitis (Non-Live Vaccine)
Vaccinate at-risk patients (college students, military recruits) if not previously vaccinated regardless of immunosuppression.
Pneumococcal Pneumonia (Non-Live Vaccine)
If not immunosuppressed: Consider vaccination with PSV23 (Pneumovax®). If immunosuppressed: Vaccinate with PCV13 (Prevnar®) followed by PSV23 (Pneumovax®) ? 8 weeks later followed by PSV23 booster after 5 years.
Vitamin D 25-OH Level
Serial monitoring of vitamin D levels, supplement if deficient.
Assess bone density if the following conditions are present:
Prescription of Calcium & Vitamin D
Co-prescription of calcium and vitamin D tablets for all patients with each course of oral corticosteroids and if vitamin D deficient or insufficient.
Mesalamines
Annual renal function monitoring.
Corticosteroids – See Bone Health
Document plan and use of corticosteroid-sparing therapy. Consider ophthalmology exam.
Thiopurines
TPMT, CBC, and liver function prior to initiating therapy. Routine CBC and liver function monitoring while on therapy.
Methotrexate
CBC, liver, and renal function prior to initiating therapy. Routine CBC, liver, and renal function monitoring while on therapy
Anti-TNFa/Anti-IL-12/23
Tuberculosis (TB) screening prior to initiating therapy with PPD skin testing and/or QuantiFeron-TB Gold assay. Chest X-Ray if high-risk and/ or indeterminate PPD or QuantiFeron-TB Gold. Perform annual TB risk assessment and consider re-testing if high risk (including travel to endemic region). See Hepatitis B vaccine. CBC, liver, and renal function prior to initiating therapy and periodic monitoring while on therapy.
Natalizumab
Enrollment in TOUCH program. Check JCV antibody and treat if negative. Retest JCV antibody q 4-6 months prior to initiating therapy. Routine CBC and liver function monitoring while on therapy.
Vedolizumab
CBC, liver, and renal function prior to initiating therapy and periodic monitoring while on therapy.
Tofacitinib
CBC, liver, fasting lipid profile, and tuberculosis (TB) screening with PPD skin testing and/or QuantiFeron-TB Gold assay prior to initiating therapy. Chest X-Ray if highrisk and/or indeterminate PPD or QuantiFeron-TB Gold. Perform annual TB risk assessment and consider re-testing if high risk (including travel to endemic region). Routine CBC and liver function monitoring while on therapy. Fasting lipid profile 4-8 weeks after initiating therapy.
Screen for risks of thrombosis at https://www.mdcalc.com/caprini-score-venous- thromboembolism-2005. Consider alternative therapies if high risk. History of prior varicella (chicken pox) infection, varicella vaccination or seropositive for varicella: vaccination against HZV should be strongly considered when treating with tofacitinib. The recombinant non-live vaccine is preferred, and necessary if the patient is already on immunosuppresive therapy.
Colon Cancer
If ulcerative colitis beyond the rectum or Crohn’s is present in at least 1/3 of the colon, perform annual or biannual surveillance colonoscopies for
neoplasia detection after 8 years of disease. High definition scopes preferred; augmented imaging (NBI or dye-spray) and targeted biopsies recommended.
Cervical Cancer
Annual PAP smears if immunocompromised.
Skin Cancer
Annual visual exam of skin by dermatologist if immunocompromised and recommend sun exposure precautions.
Assessment of anatomic location and activity
Smoking Cessation
Discuss at every visit.
Nutritional Assessment
B12 if ileal disease or resection, iron panel. Assess for risk of malnutrition.
Behavioral Health
Screen and address mental health co-morbidities.
Wasan SK et al. Am J Gastroenterol. 2010;105(6):1231-1238. Kornbluth A et al. Am J Gastroenterol. 2010;105(3):501-523. National Cancer Institute Web site. Skin Cancer Screening (PDQ®). March 1, 2013. http://www.cancer.gov/cancertopics/pdq/screening/skin/HealthProfessional. Accessed April 5, 2013.
Qiagen® Web site. Professional guidelines cervical cancer screening. http://thehpvtest.com/about-the-digene-hpv-test/guidelines-for-hpv-testing/?Langua geCheck=1. Accessed April 5, 2013. The American Congress of Obstetricians and Gynecologists Web site. http://www.acog.org. Accessed April 5, 2013.
Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018. Jan 26;67(3):103-108
Rubin, L.G., et al. 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host. Clin Infectious Dis; Dec 2013.
1. https://www.mdcalc.com/caprini-score-venous-thromboembolism-2005, accessed Feb 9, 2020.
2. https://www.cdc.gov/vaccines/vpd/shingles/hcp/index.html, accessed Feb 9, 2020.
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