One of the sessions I delved deeply into on the first day of AIBD was “Clarifying Complications of Therapy”, which began with a presentation by Dr. Laurent Peyrin-Biroulet, MD from Nancy University Hospital, on malignancy (cancer) in IBD patients. Following Dr. Peyrin-Biroulet, was a presentation on infectious complications in IBD, by Dr. Edward V. Loftus Jr., MD from the Mayo Clinic.
Before delving into the details of risks and complications associated with immunosuppressive therapy, let us first outline which factors play into how immunosuppressed an individual is. First and foremost, not every patient with IBD is inherently immunosuppressed, rather only those who are on immunosuppressive medications fall into this category. Even amongst patients on the same drug, the following factors alter the amount of immunosuppression an individual may experience:
Increased age
Malnutrition
Comorbidities
Medications
Hospitalization
In other words, if two patients are both on the same immunosuppressive drug, but patient A is 20 years old with no comorbidities, and patient B is 60 years old and has COPD, patient B may be at a higher risk.
During the presentation on cancers in IBD patients, Dr. Peyrin-Biroulet noted that the focus was on anti-TNF drugs specifically, and that no robust data was available for other immunosuppressants. I want to make note of that, because this data does not speak for all IBD treatments, or all IBD patients.
Three of the cancers that were discussed in this presentation were skin cancers, lymphoma, and cervical cancer, all of which are associated with heightened risk in IBD patients who are immunosuppressed. That being said, Dr. Peyrin-Biroulet noted certain measures physicians can take to mitigate these risks as much as possible. I’ve created a simplified outline below for each of the cancers discussed:
Skin Cancer
Risk: there is an increased risk of non-melanoma skin cancer in IBD patients.
Prevention: use of sun protection and skin surveillance.
Lymphoma
Risk: there is a risk of lymphomas in IBD patients who are immunosuppressed.
Prevention: avoid more than 2 years of combination therapy in young males, and for older males who have tested positive for Epstein-Barr in their past, restrict the use of thiopurine drugs such as 6-Mercaptopurine (6MP), and azathioprine, as they may pose a greater risk of lymphoma in the patient.
Cervical Cancer
Risk: there is an increased risk of cervical dysplasia and cervical cancer in IBD patients.
Prevention: HPV vaccine is recommended to protect against HPV, which may lead to cancer.
In addition to Dr. Peyrin-Biroulet’s presentation on cancers associated with IBD and immunosuppression, Dr. Loftus spoke to the increased risk of other types of infections among immunosuppressed IBD patients. This included an increased risk of fungal infections, an increased risk for herpes zoster, and the importance of testing (and if necessary, treating) tuberculosis prior to starting anti-TNF therapy.
In the presentation, Dr. Loftus included a table that I found interesting and informative on determining whether or not to pause immunosuppressant treatment for IBD during an infection, in addition to treating the infection. I’ve simplified the table below, and added examples to the different drug classifications. Please note to consult with your doctor before making any changes to your actual drug treatment plan.
For Thiopurine (Including azathioprine and 6-mercaptopurine [6MP]):
Viral: you may need to stop immunosuppressants
Bacterial: stop, then individualize plan
Fungal: stop, then restart when cleared
C.Diff: continue
For Anti-TNF (Including but not limited to infliximab and adalimumab):
Viral: probably OK to continue (exception of Hepatitis B)
Bacterial: stop, then individualize plan
Fungal: stop, then restart when cleared
C.Diff: continue
Anti-Integrins (Including but not limited to vedolizumab):
Viral: continue
Bacterial: continue
Fungal: continue
C.Diff: continue