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.