Thread by @JosephHabibi_MD

@MondayNightIBD 2/📣#IBD & meds carry an⬆️risk of #Malignancies, including lymphomas

🔺Who is at risk?
🔺Is it IBD-mediated or drug-related?
🔺What is our prevention & screening🔎strategy?

Thank you for joining this special #MondayNightIBD #Back2Basics @DuekerJeffrey

@MondayNightIBD @DuekerJeffrey @amelia_kellar @DCharabaty @IBD_Afzali @drdani23 @ibddoctor @EdithHoMD @fgomollon @IBD_DrEMF @ibdgijami @MaiaKayalMD 3/ 🔥IBD may carry a unique risk of primary intestinal lymphoma (PILD), but NO🔼risk of extra-intestinal NHL

In CESAME population,
▪️Crude IR of PILD was 0.12/1000 patient-years (py)
▪️All B-cell NH LD
▪️79% ♂️, 11 CD, 3 UC
▪️86% arose in IBD lesions
▪️45% were EBV positive

@MondayNightIBD @DuekerJeffrey @amelia_kellar @DCharabaty @IBD_Afzali @drdani23 @ibddoctor @EdithHoMD @fgomollon @IBD_DrEMF @ibdgijami @MaiaKayalMD @JChristieMD @KDeFelice_IBD @dunleavy_katie @IBDMD @MN_GIMD @SaraElOualiMD @nloganmd @KrugCleveland @PDulaiMD @PriSantiagoMD 4/ Lymphoma in #IBD is mostly linked to IBD therapy, particularly #Thiopurines (6MP, AZA)

🔺⬆️Risk in CD, less evidence with UC
🔺M>F
🔺Risk increases with exposure⏲️, particularly >2 years
🔺Risk decrease after cessation of AZA

@MondayNightIBD @DuekerJeffrey @amelia_kellar @DCharabaty @IBD_Afzali @drdani23 @ibddoctor @EdithHoMD @fgomollon @IBD_DrEMF @ibdgijami @MaiaKayalMD @JChristieMD @KDeFelice_IBD @dunleavy_katie @IBDMD @MN_GIMD @SaraElOualiMD @nloganmd @KrugCleveland @PDulaiMD @PriSantiagoMD @P_DeepakIBDMD @RajeshKris @DVinsard @IBD_GorenMD @RuneWilkens @ShimaghavimiMD @IBDimmunology @RestelliniS @drsusankais @IBD_Sir 5/ 3 main types of thiopurine-associated lymphoma 👇
🔺2 EBV-mediated (young vs old onset), 1 non-EBV
🔺 All rare but 2/3 fatal

📍EBV-associated lymphoma Risk:
⚠️↑ w/ duration of thiopurine use
⚠️↑ w/ combo Rx

⚠️Normalize w/🛑thiopurines

@MondayNightIBD @DuekerJeffrey @amelia_kellar @DCharabaty @IBD_Afzali @drdani23 @ibddoctor @EdithHoMD @fgomollon @IBD_DrEMF @ibdgijami @MaiaKayalMD @JChristieMD @KDeFelice_IBD @dunleavy_katie @IBDMD @MN_GIMD @SaraElOualiMD @nloganmd @KrugCleveland @PDulaiMD @PriSantiagoMD @P_DeepakIBDMD @RajeshKris @DVinsard @IBD_GorenMD @RuneWilkens @ShimaghavimiMD @IBDimmunology @RestelliniS @drsusankais @IBD_Sir @RPanaccione @IBD_Houston @IBDHorizons @HorstIBDDoc @IBDConference @CCYANetwork @fionna_kopp @KevinWatsonJrMD @BenjaminGoldman @aboutIBD 6/ What about TNF inhibitors (TNFi) in IBD?

🤔Several contradicting studies on whether the effect is solely explained by AZA combination w/ TNFi (sample large studies included 👇)

⚠️Pooled data of high-quality papers shows risk of lymphoma w/ TNFi < AZA < Combo, all >general👪

@MondayNightIBD @DuekerJeffrey @amelia_kellar @DCharabaty @IBD_Afzali @drdani23 @ibddoctor @EdithHoMD @fgomollon @IBD_DrEMF @ibdgijami @MaiaKayalMD @JChristieMD @KDeFelice_IBD @dunleavy_katie @IBDMD @MN_GIMD @SaraElOualiMD @nloganmd @KrugCleveland @PDulaiMD @PriSantiagoMD @P_DeepakIBDMD @RajeshKris @DVinsard @IBD_GorenMD @RuneWilkens @ShimaghavimiMD @IBDimmunology @RestelliniS @drsusankais @IBD_Sir @RPanaccione @IBD_Houston @IBDHorizons @HorstIBDDoc @IBDConference @CCYANetwork @fionna_kopp @KevinWatsonJrMD @BenjaminGoldman @aboutIBD @IBD_FloMD @KatieFalloonMD @IbdClub @bottomlineibd @UmaMahadevanIBD @UChicagoIBD @moss_md @DrRosenIBD 7/Beyond TNFi and AZA/6MP, lymphoma risk does not seem to be an issue in other immunomodulatory or advanced IBD therapies:

▪️ Questionable📊on MTX/Corticosteroids, mostly extrapolated from non-IBD👪

▪️ Safety signals for newer agents, from large registries in RA, psoriasis, etc

@MondayNightIBD @DuekerJeffrey @amelia_kellar @DCharabaty @IBD_Afzali @drdani23 @ibddoctor @EdithHoMD @fgomollon @IBD_DrEMF @ibdgijami @MaiaKayalMD @JChristieMD @KDeFelice_IBD @dunleavy_katie @IBDMD @MN_GIMD @SaraElOualiMD @nloganmd @KrugCleveland @PDulaiMD @PriSantiagoMD @P_DeepakIBDMD @RajeshKris @DVinsard @IBD_GorenMD @RuneWilkens @ShimaghavimiMD @IBDimmunology @RestelliniS @drsusankais @IBD_Sir @RPanaccione @IBD_Houston @IBDHorizons @HorstIBDDoc @IBDConference @CCYANetwork @fionna_kopp @KevinWatsonJrMD @BenjaminGoldman @aboutIBD @IBD_FloMD @KatieFalloonMD @IbdClub @bottomlineibd @UmaMahadevanIBD @UChicagoIBD @moss_md @DrRosenIBD 8/🙅🏻‍♀️Prevention‍ strategies for lymphoma in IBD:
✔️De-escalate if combo when able
✔️Consider non-thiopurine IS/MTX
✔️Pediatric vs adult debate:
- EBV testing not routinely performed in adults
- MTX is often chosen for combo therapy in pediatrics

Any input from #PedsIBD?

@MondayNightIBD @DuekerJeffrey @amelia_kellar @DCharabaty @IBD_Afzali @drdani23 @ibddoctor @EdithHoMD @fgomollon @IBD_DrEMF @ibdgijami @MaiaKayalMD @JChristieMD @KDeFelice_IBD @dunleavy_katie @IBDMD @MN_GIMD @SaraElOualiMD @nloganmd @KrugCleveland @PDulaiMD @PriSantiagoMD @P_DeepakIBDMD @RajeshKris @DVinsard @IBD_GorenMD @RuneWilkens @ShimaghavimiMD @IBDimmunology @RestelliniS @drsusankais @IBD_Sir @RPanaccione @IBD_Houston @IBDHorizons @HorstIBDDoc @IBDConference @CCYANetwork @fionna_kopp @KevinWatsonJrMD @BenjaminGoldman @aboutIBD @IBD_FloMD @KatieFalloonMD @IbdClub @bottomlineibd @UmaMahadevanIBD @UChicagoIBD @moss_md @DrRosenIBD 9/ With all this information, how can we be the patient's best advocate?

🌟Pts deserve ALL info delivered in clear & understandable format
🌟Pts +👩‍⚕️build trust around choosing best treatment course, after proper risks and benefits portrayed
🌟Create monitoring & txt switch plans

@MondayNightIBD @DuekerJeffrey @amelia_kellar @DCharabaty @IBD_Afzali @drdani23 @ibddoctor @EdithHoMD @fgomollon @IBD_DrEMF @ibdgijami @MaiaKayalMD @JChristieMD @KDeFelice_IBD @dunleavy_katie @IBDMD @MN_GIMD @SaraElOualiMD @nloganmd @KrugCleveland @PDulaiMD @PriSantiagoMD @P_DeepakIBDMD @RajeshKris @DVinsard @IBD_GorenMD @RuneWilkens @ShimaghavimiMD @IBDimmunology @RestelliniS @drsusankais @IBD_Sir @RPanaccione @IBD_Houston @IBDHorizons @HorstIBDDoc @IBDConference @CCYANetwork @fionna_kopp @KevinWatsonJrMD @BenjaminGoldman @aboutIBD @IBD_FloMD @KatieFalloonMD @IbdClub @bottomlineibd @UmaMahadevanIBD Hope you learned something new from this 🧵 and thank you for joining.

Join @MondayNightIBD again on March 6 for an interesting case of IBD complicated by lymphoma, help us figure out what to do! Guest @DuekerJeffrey @DCharabaty