Case 16.3

Fortunately, this patient has discussed transition and transfer with her previous pediatric Gastroenterologist, and she has acquired many self-management skills. She found an adult GI provider after an internet search, and together you plan a joint video visit with her new provider in the next 6-12 months.

You then discuss healthcare maintenance with the patient. A bone densitometry scan in 2013 showed osteopenia with a Z-Score of -3.1 and repeat in 2018 demonstrated ongoing osteopenia. She is seen by pediatric Endocrinology who recommend avoiding steroids, optimizing vitamin D level, and a program of weight-bearing exercise. She also sees an Ophthalmologist yearly with a recent normal exam. Her last colonoscopy was done at age 19 using high-definition white light.

Her follow-up with Endocrinology and Ophthalmology visits are scheduled. What other healthcare maintenance considerations would you address with this patient at your visit? Select all that apply.

Make sure she is up to date on her vaccines

IBD patients should receive the COVID-19 vaccine, HAV/HBV vaccine, annual influenza vaccine, pneumococcal vaccine, Td or TDaP booster, HPV vaccine, and, if considering Tofacitinib, recombinant zoster vaccine if

Discuss the timing and important of Papanicolaou smears.

Women with IBD on chronic immunosuppression, particularly thiopurines, should undergo annual Pap smears for cervical cancer screening starting one year after initiation fo sexual activity, but no later than age 21.

Remind her of annual skin exams by her new Primary Care Physician or Dermatology.

Thiopurines and anti-TNFs have been reported to increase the risk of both non-melanomatous skin cancers and melanoma. Patients exposed to these drugs should undergo yearly skin checks and limit sun exposure.

Refer her to nutrition to begin a gluten-free diet.

This is unnecessary unless she has signs or symptoms of celiac disease.

Begin colorectal cancer surveillance.

Current guidelines recommend initiation of colorectal cancer screening beginning 8 years after diagnosis in patients with UC or Crohn's colitis or at the time of diagnosis of primary sclerosing cholangitis.

You recommend a surveillance colonoscopy, but the patient will soon be changing health insurance plans due to her new job as an Emergency Medical Technician. Her parents are also moving, so this will be the first colonoscopy that the patient will undergo without having them nearby.

What are patient factors that can make transition to an adult healthcare model challenging? Select all that apply.

Financial stressors

Depression

Lack of trust in pediatric IBD provider

Most transitioning patients feel ready to transition by age 21

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