About two-thirds of inflammatory bowel disease (IBD) specialists worldwide support continuing IBD medications when traveling to tuberculosis (TB)-endemic areas, while about half offer pre-travel advice. The data also show that more awareness of vaccination guidelines is needed.
The real-world study with that information, “A Global Survey of Gastroenterologists’ Travel Advice to Patients with Inflammatory Bowel Disease on Immunosuppressive Agents and Management of Those Visiting Tuberculosis-Endemic Areas,” was published in the Journal of Crohn’s and Colitis.
Patients with IBD who take immunosuppressants are exposed to infections, including those that are vaccine-preventable, in their travels. Also, their risk of venous thromboembolism (VTE) a blood clot that starts in a vein — increases with long-distance travel.
As such, they would benefit from pre-travel advice on preventive measures and education, adequate medical insurance, and a plan for emergency self-treatment.
Using immunosuppressants in combination with treatment targeting tumor necrosis factor — a key molecule in inflammatory response — elevates the risk of TB reactivation. However, the management of IBD patients on immunosuppressants when traveling to TB-endemic countries still requires a standardized approach.
The multi-national team from Australia, China, the U.K. and Singapore intended to determine the proportion of gastroenterologists providing travel-related recommendations to IBD patients, and which topics are being covered. Also, the investigators aimed to analyze how physicians manage IBD patients on biological therapy and visiting TB-endemic areas.
They employed a survey with 57 questions and divided into demographic information – medical position, country, years in practice, number of IBD patients evaluated monthly, and practice type and location – travel-specific vaccinations, TB, travellers’ diarrhea, VTE, and medical insurance.
IBD specialists were defined as gastroenterologists caring for more than five IBD patients per month. Two case scenarios were used to assess physicians’ strategy on the use of immunosuppressants in IBD patients travelling to TB-endemic areas.
And the survey said …
A total of 305 of the 376 physicians met the inclusion criteria. They were from 23 countries — mainly from Australia, U.K., Italy, Israel, and Canada — representing five continents. Most (67.1%) worked in public hospitals and treated over 10 patients with IBD per week. They had 13.4 mean years of gastroenterology experience.
The data showed that only 52% of respondents offered travel-related advice at least frequently. Those seeing more than 10 IBD patients per week gave travel advice more frequently.
Travelers’ diarrhea (90.8%), travel vaccines (88.9%), medical care and travel insurance (88.9%), TB (72%), malaria (67.2%) and VTE (62%) were frequently covered. In contrast, high-altitude journeys and flights were discussed by only 35% of physicians.
As for the case scenarios, the first described a young male with ileocolonic (affecting the ileum and the colon) Crohn’s disease (CD) — a main type of IBD — in steroid-free remission. He was planning a one-month travel to India (a TB-endemic country) and was on maintenance anti-TNF therapy Remicade (infliximab, Janssen Immunology) and immunosuppressant azathioprine.
Results of this first case revealed that 47% of physicians agreed to advise the patient not to travel, while 33% disagreed. Only 8.9% considered that the patient should take anti-TB prophylactic (preventive) antibiotics. Also, 65% of respondents endorsed the continuation of both IBD treatments, but less than 10% supported stopping immunosuppressant therapy before travelling.
Nearly 60% of physicians disagreed with changing to treatment with Remicade only, while approximately 66% said they would refer to a travel clinic doctor. Advising on the risks of contacting TB while on anti-TB treatment was supported by 95% of gastroenterologists.
Case two described the same patient but on Entyvio (vedolizumab, by Millenium Pharmaceuticals) instead of Remicade. Of note, Entyvio binds to a protein called alpha-four-beta-seven integrin, blocking the interaction between white blood cells and blood vessels in the gastrointestinal tract.
In this second case, fewer physicians (17.6%) would recommend not to travel, while more (61.5%) disagreed. “The data suggested that the risk of developing TB among IBD patients undergoing anti-TNF therapy might be substantially higher in TB-endemic areas,” the scientists wrote.
Also, more (75.7%) disagreed with using anti-TB prophylactic antibiotics. Between 78-92% did not agree with stopping immunosuppressants before traveling. A similar proportion, as in case one, 68.9% supported continuing both medications, while 29.9% would keep Entyvio only. Also, more physicians agreed with vedolizumab than with anti-TNF standalone therapy (29.9% vs 23%).
Nearly two-thirds of physicians, especially those in North America (85.7%) said the patient should be referred to a travel clinic.
Chest X-ray and interferon-gamma-release assay were the preferred methods to assess TB infection, with one-third of respondents supporting tests before and after traveling.
The results also showed that 30-70% of physicians, especially those who finished their training programs more than 20 years ago, were not familiar with the Centers for Disease Control and Prevention– recommended vaccines prior to travel; those include cholera, hepatitis A, Japanese encephalitis, rabies, typhoid, and malaria.
Regarding VTE prevention, the physicians recommended adequate hydration during flight (93.4%), leg exercises during flight (96.8%), and use of graduated compression stockings (58.2%).They also were more supportive of conservative approaches for travelers’ diarrhea, supporting food and water precautions (97.6%), seeking medical advice (95.4%), and antibiotics if diarrhea is severe (87.2%).
“In conclusion, this study showed that about half of the IBD specialists are willing to discuss with their patients travel-related issues, including travelers’ diarrhea, specific travel vaccines, medical care and health insurance abroad, TB and malaria,” the researchers wrote. “Knowledge of vaccines among IBD physicians is inadequate,” they added.