Managing IBD in the Elderly Population

When managing inflammatory bowel disease (IBD) among elderly patients while taking into account complications from comorbid conditions, “there is no ‘one drug’,” that works for all older patients, Emanuelle Bellaguarda, MD, stressed during her presentation at the Advances in Inflammatory Bowel Disease Regionals meeting in Chicago, Illinois, on July 23.

Dr. Bellaguarda is an assistant professor of medicine in the gastroenterology and hepatology division at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

As the prevalence of IBD increases rapidly worldwide, it is imperative to mitigate the burden of the disease, she explained. Dr. Bellaguarda noted that the elderly subgroup (defined as patients older than 60 years) accounts for roughly 15-20% of all new IBD diagnoses. Incidence rates are reported as high as 18.9 per 100,000. “The prevalence will increase from 976 cases per 100,000 individuals in 2018 to 1370 cases per 100,000 by 2030, according to recently published data from Canada,” she added.

Managing IBD in older patients is far more complex than managing the disease in younger patients, she said. Age increases the risk of disease complications and multiple comorbidities, which in turn makes the treatment choices much more complex. Because older patients are often excluded from clinical trials, they are under-represented in medical studies and observations. Significant data are lacking on polypharmacy, which is especially important among senior patients with IBD, who often take 3 or more prescribed medications. In addition, Dr Bellaguarda said, the symptoms of IBD among seniors are 4 times more likely to be misdiagnosed than among younger patients, so older patients often wait longer to receive a definitive diagnosis.

The increased prevalence of frailty among the older population adds to the complexity of IBD management. Evidence has shown that frailty is independently associated with increased mortality and readmission in hospitalized patients, Dr. Bellaguarda noted. A 2021 report on morbidity rates and rehospitalization of frail adults vs non-frail adults with IBD revealed that frailty was directly associated with 57% higher risk of mortality, a 21% greater risk of readmission for all causes, and a 22% higher risk of readmission for severe IBD. Patients who were considered frail also spent more days in the hospital annually (median 9 days), in turn increasing hospitalization costs. “Infections, rather than IBD, were the leading cause of hospitalizations,” Dr. Bellaguarda added.

In terms of medication utilization patterns, Dr Bellaguarda observed a recent increase in the use of aminosalicylate monotherapy among older patients with CD and UC. However, she stated, there is “evidence demonstrating a lack of effectiveness in CD and risk of suboptimal treatment of moderate-to-severe UC” of using aminosalicylates alone.

In the case of thiopurines, Dr Bellaguarda said that evidence suggested that the use of thiopurines for more than 12 months reduced the risk of colectomy by up to 70% among older patients with IBD. “EPIMAD reported a 3% probability of starting thiopurine within the first year of diagnosis and only 16% over the course of their lifetime,” said Dr. Bellaguarda. The low rate of thiopurine use may be attributable to the increased risk of adverse events among older patients, particularly hepatotoxicity and myelotoxicity. In this cohort, 30.8% developed a clinical relapse and 36.0% required surgery, she noted.

Elaborating on the effect of vedolizumab in treating patients with IBD, Dr Bellaguarda said that while vedolizumab is effective in managing IBD in both younger and older patients equally, there is an increased risk of infections seen in the older patients. The risk of infections could be associated to both the age and the underlying diseases.

However, the risk of infections from vedolizumab was lesser than that from the use of anti-TNFs in the treatment of IBD among older patients. Evidence shows that the risk of infections post the first anti-TNF administered was higher in older patients as compared to the younger patients with IBD (4.92 vs 1.29). The serious adverse event rate, too, was higher among the older patients vs the younger patients (61.2 vs 12.4) “There is still a lower risk of infection requiring hospitalization with vedolizumab when compared to anti-TNF,” Dr. Bellaguarda explained.

Speaking of the effect of ustekinumab on IBD, Dr Bellaguarda stated that it was a safer and more effective drug in managing IBD in older population vs younger patients. Studies revealed that on a regression model, age was not associated with clinical outcomes. Mucosal healing was achieved in 26% elderly and 30% non-elderly patients, Dr Bellaguarda said. With no major differences among the older patients compared to the younger patients for infusion reactions (6.4% vs 2.6%), infections (7.7% vs 5.2%) or post-surgical complications, Dr Bellaguarda said ustekinumab was safer and effective in treating IBD in senior patients.

So what are the options in better treating IBD in the older patients? “There is no ‘one drug’ for the elderly patient,” stresses Dr. Bellaguarda. Based on the severity of disease, disease progression, prior medication exposure, and individual risk, clinicians need to come up with personalized treatment for patients. Considering physical therapy assessment and providing nutritional support could be key to improving bone, muscle, and mental health. Special attention should also be given to the psychosocial needs of the patients in terms of increased screening for depression and possible association with dementia.

IBD was originally considered to be a disease of the younger ages. However, the number of older adults with IBD is increasing rapidly—both as patients who were diagnosed when younger age, and as more older adults are diagnosed with IBD. While the symptoms and the intensity of IBD in older patients may differ from that of the younger patients, the end goals for managing the disease remain the same, Dr Bellaguarda said.

“With considerations that are unique to the older subgroup and considerable thought in selecting the appropriate drug therapy in their treatment," Dr Bellaguarda stressed, "it is possible to overcome the challenges in the long-term treatment of IBD in the elderly patient.”

—Priyam Vora

Reference:
Bellaguarda E. Management of the Elderly Patient with IBD. Presented at: Advances in Inflammatory Bowel Disease Regionals; July 23, 2022. Chicago, IL