The American Gastroenterological Association has published a Clinical Practice Update for management of inflammatory bowel disease (IBD) in elderly patients, including 15 best practice advice statements.
According to lead author Ashwin N. Ananthakrishnan, MD, MPH, of Massachusetts General Hospital and Harvard Medical School, both in Boston, and colleagues, this topic is becoming increasingly relevant, as the population is aging, and prevalence of IBD among elderly is rising approximately 5% per year.
“Up to 15% of IBD in North America and Asia is diagnosed after the age of 60 years,” the investigators wrote in Gastroenterology.
Dr. Ananthakrishnan and colleagues noted that “care of elderly IBD patients poses unique challenges with respect to diagnosis and therapeutic decision-making.”
Challenges include greater frequency of comorbidities, increased risk of infection with anti–tumor necrosis factor therapy, increased risk of lymphoma with thiopurine therapy, greater likelihood of surgical complications, and, for Crohn’s disease, an elevated mortality rate, according to the update.
Another challenge is a lack of data.
“It should be noted that most clinical data to inform these practices are based on observational data or indirect evidence as elderly IBD patients comprise a very small proportion of subjects enrolled in IBD clinical trials or long-term pharmacovigilance initiatives,” the investigators wrote.
With this in mind, the update offers guidance for diagnosis, treatment, and ongoing health maintenance.
Diagnosis
Dr. Ananthakrishnan and colleagues first suggested that clinicians remain vigilant for IBD in elderly people, in consideration of the 15% prevalence rate in this subpopulation.
For elderly individuals with a low probability of IBD, the investigators recommended fecal calprotectin or lactoferrin to determine if endoscopy is needed. For elderly patients with chronic diarrhea or hematochezia, plus moderate to high suspicion of IBD, colorectal neoplasia, or microscopic colitis, they recommended colonoscopy.
Lastly, the expert panel suggested that elderly patients presenting with segmental left-sided colitis and diverticulosis may also have Crohn’s disease or IBD unclassified.
Treatment
The clinical practice update offers 10 best practice statements for treating elderly patients with IBD. There is a recurring emphasis on treatment personalization, which should be informed by patient goals and priorities, risk/presence of severe disease, chronological age, functional status, independence, comorbidities, frailty, and several other age-associated risk factors (e.g., venous thromboembolism).
Concerning specific therapies, the investigators cautioned against systemic corticosteroids for maintenance therapy; instead, nonsystemic corticosteroids (e.g., budesonide) are favored, or possibly early biological therapy if budesonide is not indicated. When selecting a biologic, Dr. Ananthakrishnan and colleagues recommended those associated with a lower risk of malignancy and infection (e.g., ustekinumab or vedolizumab).
The advantages of thiopurine monotherapy being oral, relatively inexpensive compared to biologicals and having a long track record of success in maintenance of remission must be balanced against the need for ongoing serological monitoring, and increased risk of some malignancies.
Finally, the expert panel recommended that all elderly patients receive multidisciplinary care, which may include primary care providers, mental health professionals, nutritionists, and other specialists. It may also be productive to consult with family and caregivers during treatment planning.
Health maintenance
The last two best practice advice statements concern health maintenance.
First, the investigators recommended that elderly patients with IBD adhere to vaccination schedules, including herpes zoster, pneumococcus, and influenza vaccines, ideally, before starting immunosuppression.
Second, Dr. Ananthakrishnan and colleagues advised that cessation of colorectal cancer surveillance may be considered in elderly patients with IBD; however, this decision should take into account a variety of factors, including comorbidities, age, life expectancy, likelihood of endoscopic resection, and surgical candidacy.
The review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board. The investigators disclosed relationships with Gilead, Sun Pharma, Kyn Therapeutics, and others.
SOURCE: Ananthakrishnan AN et al. Gastroenterology. 2020 Sep 30. doi: 10.1053/j.gastro.2020.08.060.
This story was updated on 12/4/2020.