JLE

Hépato-Gastro & Oncologie Digestive

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Preventing and handling complications of immunosuppressive therapy in IBD patients Volume 20, issue 4, Avril 2013

Authors
Hôpital Saint-Antoine, service de gastro-entérologie et nutrition, 184 rue du faubourg Saint-Antoine, 75571 Paris CEDEX 12, France ; UPMC Univ Paris 06, GRC n o 03, SUVIMIC, F-75012, Paris, France

In patients with inflammatory bowel disease (IBD), immunosuppressive therapy (IT) tends to be initiated early in the disease, extensively and for prolonged periods. As a consequence, preventing and handling complications of IT is becoming an essential part of the management of IBD. Myelotoxicity is a major complication of cytotoxic drugs that justifies sustained blood monitoring. The diagnosis of portal hypertension under long-term treatment with thiopurines, and methotrexate-induced pneumonitis, should lead to definite withdrawal of the treatments. The risk of serious infections is increased under IT. Vaccination against varicella in IBD patients with no previous history of varicella is recommended before the initiation of IT. In EBV-seronegative patients, particularly young males, preferring immunosuppressive therapies that do not include thiopurines should be individually discussed because of the risk of fatal mononucleosis. Appropriate prevention and management of serious infections favored by IT rely on the respect of dedicated guidelines and the multidisciplinary approach of infectious events. The risk of lymphomas is increased in patients treated with thiopurines. Avoiding combination of thiopurines and anti-TNF in young males beyond 2-year duration can reduce the risk of hepatosplenic T-cell lymphoma. Sunscreen protection and dermatological surveillance are indicated lifelong in patients treated with thiopurines, and all along the treatment in patients treated with anti-TNF therapy. Yearly screening for cervical abnormalities is recommended in women with IBD who are exposed to IT. The risk of cancer recurrence in patients with a past history of cancer should be individually discussed before introduction of IT. The use of IT should be cautious in patients over the age of 65 years, who are at the highest risk for lymphomas and serious infections.