Preventive care in inflammatory bowel disease

Red Flags

Severe opportunistic infection on biologic or JAK inhibitor (CMV colitis, disseminated VZV, PJP) — hospitalisation; pause immunosuppression; ID consult^[1]
Newly diagnosed IBD with positive latent TB (IGRA or Mantoux ≥5 mm) before anti-TNF — treat latent TB ≥1 month before starting biologic^[1]
Live vaccine (MMR, varicella, yellow fever, oral typhoid, BCG) request while on biologic, JAK inhibitor, or high-dose corticosteroid — contraindicated; defer or use inactivated alternative^[1]
New skin lesion in IBD on thiopurine or anti-TNF — dermatology referral (non-melanoma and melanoma skin cancer risk increased)^[1]

First-line treatment

Interventions

Inactivated vaccinations before or during immunosuppression^[1]
Influenza annually, pneumococcal (PCV20 or PCV15+PPSV23), Tdap once + booster every 10 years, HPV through age 45, recombinant zoster (RZV) ≥18 years on immunosuppression, hepatitis A and B, COVID-19 per local schedule. Inactivated vaccines safe at any time
Live vaccine timing^[1]
MMR, varicella, yellow fever, oral typhoid, BCG ideally given ≥4 weeks before immunosuppression. Contraindicated during biologic, JAK inhibitor, S1P modulator, methotrexate >0.4 mg/kg/week, prednisolone ≥20 mg/day for ≥2 weeks. Wait 1–3 months after stopping immunosuppression depending on agent
Skin cancer surveillance and sun protection^[1]
Annual full-skin examination on thiopurine or after extended thiopurine exposure; melanoma surveillance during anti-TNF use; broad-spectrum sunscreen and protective clothing
Mental health screening (PHQ-9, GAD-7)^[1]
At diagnosis and annually; depression and anxiety prevalence ≥30% in IBD; refer to psychology, gut-brain therapy, or psychiatry; treat to improve adherence and outcomes
Smoking cessation^[1]
Smoking worsens Crohn's disease activity and surgical outcomes; cessation reduces flare risk and improves response to biologics; nicotine replacement and behavioural support
Cervical cancer screening with HPV co-testing^[1]
Per general population pathway with consideration of more frequent intervals on biologic or thiopurine; HPV vaccination through age 45 in IBD even if previously offered
Colorectal cancer surveillance for IBD-colitis^[1]
Surveillance colonoscopy 8 years after disease onset for left-sided UC, extensive UC, or Crohn's colitis; high-definition white light + chromoendoscopy or NBI; intervals 1–5 years by risk

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Recombinant zoster vaccine (Shingrix)^[1]	Adjuvanted recombinant subunit vaccine	0.5 mL IM × 2 doses 2–6 months apart; ≥18 years on immunosuppression	—	Lower age threshold (≥18) for IBD on immunosuppression vs general population (≥50); preferred over zoster live vaccine which is contraindicated
Hepatitis B vaccine (high-dose / accelerated schedule)^[1]	Recombinant viral vaccine	Standard 20 µg IM at 0, 1, 6 months; consider 40 µg double-dose schedule for non-responders or on biologic	—	Check post-vaccination anti-HBs 1–2 months after series; revaccinate non-responders with double-dose 4-dose schedule

Recombinant zoster vaccine (Shingrix)^[1]

Adjuvanted recombinant subunit vaccine

Adult: 0.5 mL IM × 2 doses 2–6 months apart; ≥18 years on immunosuppression
Paediatric: —

Lower age threshold (≥18) for IBD on immunosuppression vs general population (≥50); preferred over zoster live vaccine which is contraindicated

Hepatitis B vaccine (high-dose / accelerated schedule)^[1]

Recombinant viral vaccine

Adult: Standard 20 µg IM at 0, 1, 6 months; consider 40 µg double-dose schedule for non-responders or on biologic
Paediatric: —

Check post-vaccination anti-HBs 1–2 months after series; revaccinate non-responders with double-dose 4-dose schedule

Safety-net

Tell every clinician you see (dentist, A&E, pharmacist) that you are on immunosuppression — this changes infection risk assessment and antibiotic choice^[1]
Cold sores, chickenpox, shingles, or unexplained fever — same-day medical review; specific antiviral therapy may be needed^[1]
Plan international travel ≥6 weeks ahead — some live vaccines need pre-trip pause from biologic; speak to your IBD team about itinerary^[1]

Referral criteria

Any opportunistic infection on biologic or JAK inhibitor (CMV, PJP, TB, disseminated VZV)Infectious diseases and IBD specialist^[1]
Latent TB positive before biologic startRespiratory or ID for treatment ≥1 month before biologic^[1]
Osteoporosis or fragility fractureBone-health clinic; consider antiresorptive therapy^[1]
PHQ-9 ≥10 or GAD-7 ≥10 with functional impairmentMental health referral and IBD team review^[1]

Clinical summary

Vaccination, cancer screening, bone health, mental health, and infection-risk reduction for adults with IBD on immune-modifying therapy.

References

1.ACG Clinical Guideline Update: Preventive Care in Inflammatory Bowel Disease (2025) (2025)