Appendices

Healthcare professional holding a model of the colon

Appendix A–Treatments

This table contains side effects that may be rare or specific to certain medications in a class. Therefore, it is important to check and determine the potential side effects for individual medications.

Potential medication side effects by class

Medication class	Available routes of administration	Select potential side effects
Corticosteroids	Oral or rectal	Acne Cataracts Growth disturbance in children Hirsutism Hypertension Hyperglycemia Infection Insomnia Mood swings Osteoporosis Psychosis and other psychiatric symptoms Rounding of the face (“moon face”) Stretch marks Weight gain
Aminosalicylates	Oral or rectal	Abdominal pain and cramping Decreased sperm production and function in men Diarrhea Headache Hirsutism Fever Loss of appetite Nausea Nephrotoxicity Pancreatitis Pericarditis Rash Vomiting
Immunomodulators	Oral, topical, IM, or SQ	Aphthous stomatitis Dermatologic reactions Diabetes mellitus Diarrhea Dissemination of infection with live vaccines Embryo-fetal toxicity, including fetal death Fever Gingivitis Headache Hepatitis Hepatoxicity Hirsutism/hypertrichosis Hypercholesterolemia Hypertension Insomnia Lethargy/malaise Leukopenia Musculoskeletal or joint pain Myelosuppression Nausea Nephrotoxicity Pancreatitis Pulmonary toxicity Secondary malignancies Seizure Serious infections Tingling of the fingers and feet Tremor Vomiting
Biologics*
TNF-alpha (α) inhibitors	SQ or IV	Arthritis Chills Cough Fever Headache Hives Infection, including serious infection Infusion/injection site reaction Nervous system disorders Liver toxicity Lupus-like reaction Secondary malignancies Severe allergic reaction Skin reaction
Integrin inhibitors	SQ and IV
Interleukin (IL) inhibitors	SQ and IV
Small molecules
JAK inhibitors	Oral	Acne Anemia Blood clots Death or major cardiovascular events Elevated cholesterol Fatigue Headache Infection, including serious infection Nasopharyngitis Nausea Secondary malignancies
S1P receptor modulators	Oral	Back pain Bradyarrhythmia and atrioventricular conduction delays Cutaneous malignancies Decline in pulmonary function testing Dizziness Elevated cholesterol Fetal risk Headache Infection, including serious infection Liver injury and elevated liver enzymes Macular edema Orthostatic hypotension Progressive multifocal leukoencephalopathy (PML)

Abbreviations: IM = intramuscular; IV = intravenous; JAK = janus kinase; S1P = Sphingosine-1-phosphate; SQ = subcutaneous; TNF = tumor necrosis factor.
*Some biologics may require IV as induction followed by SQ for maintenance.

Appendix B–Preventative medicine

This table contains more detailed information about suggested preventative care for IBD management.

Vaccinations	Patients with IBD are more susceptible to infection due to the immune effects of IBD as well as due to some immunosuppressive therapies for IBD. Many of these infections are vaccine preventable and several guidance documents exist regarding recommended vaccinations for patients with IBD (including the linked checklists). Administer recommended vaccines to adults with IBD before initiation of systemic immune suppression, when possible, following Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practice (ACIP) guidelines with the exception of live vaccines. Patients receiving immune-modifying agents should be counseled against receiving live vaccines. As vaccination recommendations change often, the CDC and ACIP website should be reviewed for the latest information and ongoing recommendations should be discussed with the patient’s gastroenterologist.
Smoking cessation	Cigarette smoking may worsen Crohn’s disease activity, increases the risk for complications. All patients should be screened for smoking status. Patients that currently smoke should be engaged in and/or referred for smoking cessation.
Cancer prevention	All adult patients with IBD should receive age-appropriate cancer screening. Colorectal: Patients with IBD have increased risk of colorectal cancer. Initial screening should be performed at 8-10 years after disease diagnosis for all patients with IBD. Ongoing surveillance is based on the duration and extent of disease. The AGA clinical practice update on endoscopic surveillance and management of colorectal dysplasia in inflammatory bowel diseases provides extensive recommendations regarding timing and risk factors impacting colorectal cancer screening intervals. Skin: Patients with IBD are at an increased risk for nonmelanoma skin cancer (NMSC). Sun exposure precautions (eg, sun avoidance, sunscreen, protective clothing) should be discussed with all patients with IBD. Patients on immunomodulators, anti-tumor necrosis factor (anti-TNF) biologic agents, or small molecules should undergo a yearly total body skin exam. Patients with any history of thiopurine use should continue with a yearly total body skin exam even after thiopurine cessation. Cervical: Adult women with IBD should follow age-appropriate screening for cervical dysplasia. HPV vaccination is recommended in accordance with ACIP guidelines.
Tuberculosis (TB) screening	TB screening is required before treatment with some immunosuppressive and biologic therapies due to the risk of reactivation of latent TB.
Osteoporosis/osteopenia	Bone densitometry should be considered in patients with IBD, regardless of age, when risk factors for osteopenia and osteoporosis are present. These risk factors include low body mass index (<20 kg/m²), >3 months of cumulative corticosteroid exposure, current smoking, postmenopausal status, or hypogonadism. In the absence of other factors, bone densitometry should be considered for postmenopausal women and men 65 years or older.
Nutritional assessment	Patients with IBD may be at higher risk for malnutrition. Patients should be evaluated for malnutrition, including iron panels, vitamin D, and vitamin B12. Nutrition and diet play a key role in IBD management. Collaboration with dietitians can help provide patients with comprehensive nutritional guidance. The Crohn’s & Colitis Foundation Diet and Nutrition resources can provide patients with information on what to eat, gut-friendly recipes, and guidance on finding an IBD-registered dietitian.
Mental health screening	Depression and anxiety may occur at higher rates in patients with IBD. Patients with IBD who were depressed were found to have lower medication adherence and higher disease activity scores. Patients should be screened at baseline and annually with appropriate tests, such as the General Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9). Appropriate treatment, counseling, and/or mental health referral is recommended for patients who screen positive. Several Patient resources exist that can support psychosocial aspects of care for patients.
Ophthalmologic screening	Annual eye exams are recommended, particularly for patients receiving immunosuppression or with eye-related extraintestinal manifestations.
Oral/dental health	Patients with IBD may have more oral health concerns, such as oral lesions and periodontitis, than patients without IBD. Though clear guidance on prevention or management are not available, clinicians should be aware of this risk and encourage patients to maintain good oral health and regular visits with dentists.
Pain management	Pain, particularly chronic abdominal pain, is common in individuals with IBD. Pain may be due to a variety of reasons, including acute inflammation, strictures, and obstruction. Modifiable causes of pain (eg, active disease, infective/bacterial, dysmotility) should be evaluated and treated. Multimodal and holistic pain management, including psychological, and diet and lifestyle interventions, should be considered.