Elderly IBD isn’t less severe
During a median of 4.2 years of follow-up in the Swedish national study, patients diagnosed with IBD after age 60 had more IBD-related hospitalizations and overall health care utilization than those diagnosed at ages 18-59. The incidence of extraintestinal disease manifestations was similar in the elderly and younger-adult patients; however, bowel surgery was significantly more common in the elderly patients, with a 13% rate after 5 years versus 10% in patients diagnosed as younger adults.
Moreover, elderly patients were less likely to use biologic agents and received much more systemic corticosteroid therapy than younger adults. These findings suggest that the reason elderly patients aren’t using biologics isn’t because their disease is milder, but rather because their physicians are afraid of using biologics. Due to their overconcern about risks of malignancy and serious infections, many physicians opt instead for repeated courses of corticosteroids, which is an inappropriate treatment strategy, Dr. Mahadevan said.
A cross-sectional U.S. study utilizing data from the National Inpatient Sample demonstrated that 25% of all patients hospitalized for IBD were above age 65. The study by investigators at the Medical College of Wisconsin, Milwaukee, found that age greater than 65 was an independent risk factor for in-hospital mortality. Indeed, even after adjustment for comorbidity in a multivariate logistic regression analysis, IBD patients above age 65 had a sobering 3.9-fold greater risk of in-hospital mortality (Inflamm Bowel Dis. 2009 Feb;15[2]182-9).
Another piece of evidence that elderly-onset IBD isn’t less severe comes from a Canadian cohort study of all newly diagnosed cases of IBD in Ontario during 1999-2008. The elderly-onset ulcerative colitis patients were one-third more likely to undergo IBD-related surgery than those diagnosed at ages 18-40. Older-onset Crohn’s disease patients weren’t more likely to have IBD-related operations than younger-onset patients; however, IBD-specific mortality was significantly greater in elderly-onset Crohn’s disease patients than in those diagnosed in middle age or as young adults, by a margin of 33.1 cases to 5.6 cases to 1.0 case per 10,000 person-years (Inflamm Bowel Dis. 2017 Feb;23[2]:218-23).
Treatment of IBD in the elderly
Dr. Mahadevan emphasized that, if elderly patients need biologic therapy because their disease isn’t being adequately controlled with more conservative management strategies, then they should get it. The higher rates of IBD-related surgery and in-hospital mortality in elderly IBD patients argue in favor of that strategy in order to keep them out of the hospital and optimize quality of life.
Her go-to biologics in elderly IBD patients are vedolizumab (Entyvio) and ustekinumab (Stelara): “In my older patients I reach for these two first.”