Health Maintenance in Ulcerative Colitis: 5 Things to Know

Addressing all aspects of healthcare maintenance in ulcerative colitis (UC) — one of two major types of inflammatory bowel disease (IBD) along with Crohn’s disease — can be a challenge as the management becomes increasingly complex with disease progression. Ideally, health maintenance should be co-managed by gastroenterologists and primary care providers to improve the quality of care for these patients. Patients on long-term immunomodulators and advanced therapies, including biologics and targeted small molecules, have specific needs for cancer screening and surveillance for bone and mental health status. 
Here are five things to know about helping patients with UC maintain their health.
Vaccination is essential for preventing serious infections and for reducing the risk for infections that could trigger flare-ups, particularly in immunosuppressed patients, whether it’s because of the nature of the disease or because of immunosuppressive therapy. Adults with UC should receive age-appropriate vaccines before starting immunosuppressive therapy to ensure a strong, long-lasting immune response; however, treatment for UC should not be delayed for vaccination purposes. Live vaccines, including measles, mumps, rubella, and varicella, should be avoided in patients on immunosuppressive therapy. These vaccines can be administered at least 4 weeks before patients start on immunosuppressive therapy but should be avoided within 2 weeks of initiation. Live vaccines should not be administered until at least 3 months after immunosuppressive therapy. While there are no safety concerns associated with inactivated vaccines in patients with IBD immunosuppressive therapy, the immune response may be decreased. 
Some of the main vaccines generally recommended by the American College of Gastroenterology (ACG) for patients with IBD include COVID-19, hepatitis A, hepatitis B, human papillomavirus (HPV), inactivated influenza, and pneumococcal vaccines in accordance with current US Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) guidelines. The following summarizes current recommendations for these vaccines:
COVID-19.  The 2024-2025 COVID-19 vaccine is recommended for persons aged 6 years or older. The ACIP further recommends that individuals aged 65 years or older who are moderately or severely immunocompromised receive a second dose of the 2024-2025 COVID-19 vaccine 6 months after the first dose. Per the current recommendations, patients, in consultation with their primary care provider, may receive additional doses.
Hepatitis A. Immunocompromised persons aged 12 months or older, including those on immunosuppressant medications, are at increased risk for severe hepatitis A infection. Because some patients are unsure of their hepatitis A vaccination status, it is reasonable for clinicians to perform titer testing to determine whether vaccination is indicated. The dosing schedule for the hepatitis A vaccine for adults is a two-dose series at 0 and 6-12 months or 0 and 6-18 months, depending on the vaccine given.
Hepatitis B. As with hepatitis A, clinicians should perform titer testing to determine a patient’s immune status. Nonimmune patients should receive a series of three doses of vaccine at 0, 1, and 6 months. Patients whose hepatitis B status remains nonimmune may receive a double-dose booster or the combined hepatitis A and B vaccine.
Human papillomavirus. Per current ACIP recommendations, three doses of the HPV vaccine are recommended for immunocompromised individuals, including those on immunosuppressant medications, at 0, 1-2, and 6 months.
Influenza. The ACIP recommends that immunocompromised persons receive an annual non-live trivalent inactivated influenza vaccine or non-live trivalent recombinant influenza vaccine. The intranasal trivalent live attenuated influenza vaccine is not recommended for immunocompromised patients.
Pneumococcal. The ACIP recommends pneumococcal vaccination (pneumococcal conjugate vaccines [PCV] 15, PCV20, PCV21, PPSV23) for PCV-naive adults aged 50 years or older, including those with an immunocompromised status, and in patients aged 19-49 with iatrogenic or acquired immunodeficiency. A summary of the current pneumococcal vaccination schedule is available on the CDC website.
Patients with UC are at increased risk for certain cancers, including cervical, prostate, and skin cancer. Depending on the severity of UC and other risk factors, some patients should be screened annually for these cancers. 
Even though the HPV vaccine to prevent cervical cancer is recommended for male and female patients between 9 and 45 years of age, women aged 27 through 45 years may have already been exposed to HPV by the time of vaccination. Therefore, regular screening remains the most effective approach to protect against cervical cancer. One meta-analysis showed that women with IBD on immunosuppressive medications have an approximately 1.5-fold increased risk for cervical high-grade dysplasia and cancer. The American College of Obstetricians and Gynecologists and the ACG recommend annual cervical cancer screening with Pap smear for all women with IBD who are on immunosuppressant therapy. In addition to annual screening, patients should be counseled to quit smoking, as the main factors associated with an increased risk for cervical high-grade dysplasia and cancer are cigarette smoking and immunosuppressed status. 
Several recent reports suggested that IBD is a risk factor for prostate cancer. A large retrospective US study demonstrated that men with IBD have higher rates of prostate cancer when compared with age- and race-matched controls. Another large-scale, prospective cohort study from the United Kingdom showed an association between IBD, particularly UC, and increased incidence of prostate cancer. On the basis of these findings, earlier and more vigilant screening for prostate cancer may be indicated for men with UC. The American Urological Association and Society of Urologic Oncology guideline recommends screening men at high risk for prostate cancer starting at ages 40-45 years.
Patients with IBD are at an increased risk of developing nonmelanoma skin cancer and melanoma, independent of biologic use. Patients with IBD on immunosuppressive therapy require annual skin cancer screening. In addition, given the observed increased risk for melanoma and nonmelanoma skin cancer associated with IBD, patients are generally advised to use appropriate sun protection, including sunscreen and protective clothing — regardless of whether they are on biologic therapy, as per the ACG guidelines. Patients on immunosuppressive therapies (eg, thiopurines, anti–tumor necrosis factor agents, Janus kinase inhibitors) should check themselves for signs of nonmelanoma skin cancer, especially those who are over age 50 years. Annual skin cancer screening is suggested, though the interval may be adjusted by the dermatologist on the basis of individual risk factors. 
Patients with UC involving more than just the rectum are at an increased risk of developing colorectal neoplasia, including dysplasia and colorectal cancer (CRC). Compared with the general population, the risk for CRC is 2.4-fold higher in patients with UC. In one study, the cumulative risk for CRC in patients with UC was 2% after 10 years of disease, 8% after 20 years, and 18% after 30 years. Initial screening with colonoscopy should occur 8-10 years from IBD diagnosis. 
There are limited data on the ideal surveillance intervals following the initial screening, and these intervals should be tailored to individual risk factors, such as the extent of colitis, inflammatory burden, family history of CRC, and the presence of dysplasia. In general, screening recommendations from US societies range from every 1 to 3 years for patients with negative screening colonoscopy. However, the AGA recommends surveillance every 2-3 years. High-definition colonoscopy, with or without dye spray or virtual chromoendoscopy, should be used on the basis of the endoscopist’s expertise. Adequate biopsies should be taken from each colon segment, including both targeted biopsies to rule out dysplasia and random nontargeted biopsies to detect nonvisible dysplasia, and to assess histologic disease activity and extent. Patients with primary sclerosing cholangitis have a fourfold increased risk for CRC and should undergo annual colonoscopy surveillance starting at the time of diagnosis. 
Osteoporosis and decreased bone mineral density in patients with IBD result from multiple factors, including corticosteroid use, chronic inflammation, malnutrition, and vitamin D and calcium deficiencies. The estimated prevalence of osteoporosis in patients with IBD varies from 12% to 70%, and the prevalence of osteopenia is as high as 70%. The Bone Health and Osteoporosis Foundation recommends following general population guidelines, with particular attention to women and men aged ≥ 50 years with conventional risk factors and those with specific risk factors, including IBD and prolonged corticosteroid use (prednisone ≥ 5.0 mg/d or an equivalent corticosteroid for ≥ 3 months). Patients should be counseled and assessed on the basis of individual risk factors. Serum vitamin D levels should be monitored regularly, with supplemental vitamin D as needed to maintain a serum 25-hydroxy vitamin D level ≥ 30 ng/mL but below ≤ 50 ng/mL. The recommended daily intake for vitamin D is 800-1000 IU for adults aged ≥ 50 years. In addition to vitamin D, patients should achieve recommended calcium intake for their age and sex. The recommended daily calcium intake is 1000 mg/d for men aged 50-70 years and 1200 mg/d for women aged ≥ 51 years and men aged ≥ 71 years. Calcium supplements are appropriate for patients who are unable to attain adequate calcium through diet. Daily vitamin D supplementation in patients with IBD may have a positive impact on clinical scores and quality of life. 
Anxiety and depression are more common in patients with IBD, with a prevalence of anxiety at 19.1% compared with 9.6% of healthy peers, and depression at 21.2% compared with 13.4% of healthy peers. Psychological stress has been shown to play an important role in the disease process, contributing to flare-ups and negative outcomes. Additionally, one quarter to one third of patients have significant symptoms from posttraumatic stress related to their disease and medical experiences, which has been directly linked to worse outcomes. The ACG recommends that clinicians screen patients with IBD for depression and anxiety as part of routine care for early recognition and intervention. Validated scores like the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder Questionnaire-7 (GAD-7) Scale are recommended for screening. 
In summary, collaboration between gastroenterologists and primary care providers is very important to ensure comprehensive healthcare maintenance for patients with UC, especially given the increasing number of available therapies and their effects on the immune system. This partnership helps achieve the best possible outcomes for patients.