Case 8 Discussion - IBD Learn

Learning Objectives:

Take different diagnostic considerations into account in the elderly population vs the general population.
Select appropriate medical therapy for the elderly IBD patient, taking into account contraindications and side effects.
Describe surgical outcomes for the elderly IBD patient.
Understand healthcare maintenance concerns for the elderly IBD patient.

IBD EPAs

EPA 1: Classify IBD phenotype, disease activity, and extraintestinal manifestations
EPA 2: Use advanced diagnostic and therapeutic endoscopic and radiographic techniques in the management of IBD
EPA 3: Prescribe and manage evidenced-based IBD therapies using clinical pharmacologic principles in clinical practice
EPA 6: Manage preoperative and postoperative care for patients with IBD
EPA 7: Manage IBD in special populations
EPA 10: Apply preventive health strategies for patients with IBD

Discussion:

One out of 160 elderly patients are affected by inflammatory bowel disease (IBD) either through the aging of the IBD population (existing diagnoses) or new diagnoses (incident cases). [1] Patients who are diagnosed with IBD over the age of 60 years old are considered “elderly onset IBD.” Many of the same diagnostic and treatment principles hold true in treating older patients with IBD as younger patients, though they may require special care due to a higher incidence of comorbidities, risk of polypharmacy, and risk of adverse events associated with diagnostic and therapeutic interventions.

When considering a diagnosis of IBD in an elderly patient, it is important to consider that older patients are more likely to suffer from diagnoses that are not IBD (such as microscopic colitis, colorectal cancer, ischemic colitis, SCAD, NSAID-induced pathology, radiation enterocolitis, microscopic colitis, rectal ulcer syndrome, and infectious colitis). [2] Elderly patients are also more likely to have complications from colonoscopy such as cardiopulmonary complications, GI bleeding, and perforation than younger patients. [3] Therefore, if there is a low suspicion that a diagnosis will be made by colonoscopy or procedure risk is high in a particular patient, non-invasive tests should be performed first to rule out alternate diagnoses.

With respect to disease course and prognosis, elderly patients are more likely to have isolated colonic CD and a stricturing phenotype, and less likely to have penetrating or perianal CD. Ulcerative colitis is more likely to be isolated to the left colon. [4] Fewer older-onset IBD patients are given immunomodulators and biologics. Elderly IBD patients are more likely to experience hospitalization, development of neoplasms, and surgery for UC. [5]

Unfortunately, elderly patients comprise a very small portion of clinical trial and pharmacovigilance subjects, therefore much of what we know about treating elderly IBD patients comes from observational studies and extrapolation. When planning treatment, it is important to consider that elderly patients are more likely to experience medical comorbidities and be at risk for polypharmacy than their younger counterparts. Additionally, they may be uniquely susceptible to nutritional deficiencies, and functional decline (frailty). Frailty has been shown to increase the risk of infectious complications with immunomodulators and anti-TNF therapies. [6] For these reasons, a multidisciplinary approach, including nutrition and physical therapy interventions along with collaboration with primary, geriatric, and other relevant subspecialty care, must be taken when treating elderly IBD patients.

Elderly patients may be at higher risk of specific adverse effects from IBD therapy. In particular, they are at higher risk of steroid-related adverse effects such as hypertension, diabetes, osteoporosis, cataract, fatigue, depression. Budesonide is preferred over conventional corticosteroids for this reason. Although there is ample data suggesting that 5-ASA compounds are not effective in CD, >2/3 of elderly CD patients receive them. With respect to immunomodulators, elderly patients are at a higher risk for experiencing adverse effects related to thiopurine use, such as lymphoproliferative disorder and non-melanoma skin cancer than younger patients. Elderly IBD patients may be at higher risk for complications from anti-TNF therapies such as infections and cancer, but the decision to use these should be made on a case by case basis as the benefit might outweigh the risk. There are no particular safety concerns for vedolizumab and ustekinumab in the elderly vs. young population, and these drugs may be excellent alternatives to anti-TNF therapy in the elderly population. Elderly patients taking tofacitinib are more susceptible to developing shingles, and also venous thromboembolism (VTE). The higher risk of VTE in older patients with cardiovascular disease was identified in rheumatoid arthritis patients and led to the placement of a black box warning by the Food and Drug Administration on the drug label. Despite these risks, it is important not to delay effective therapy for elderly patients with IBD, as the risk of untreated IBD may be higher than the risk of treatment.

Data are mixed with respect to surgical outcomes in elderly IBD patients. Some studies suggest higher 30-day post-operative mortality, along with other post-operative complications such as infection and VTE, however other studies have not shown such increased risk for post-operative complications. Multiple studies have shown increased length of hospital stay in the post-operative elderly IBD patient compared to younger cohorts. Historically, elderly patients with UC have not been offered IPAA surgery due to concern for poor pouch outcomes in this patient group, with end ileostomy favored. A recent study however showed that this trend is reversing, as surgeons are taking into account risk factors for poor pouch outcome when making a decision to offer IPAA, rather than limiting this surgery for all older UC patients. Independent risk factors for poor pouch outcome include obesity, prior pelvic radiation, sphincter damage or dysfunction.

IBD patients are less likely to have a primary care provider at any age and vaccinations are underutilized in this group. This is particularly important for elderly patients as they are at a higher risk for vaccine preventable illnesses such as influenza, herpes zoster, pneumococcal pneumonia, and COVID19. Elderly IBD patients should undergo annual influenza vaccination as well as appropriate inactivated zoster and pneumococcal pneumonia vaccinations. Elderly onset IBD is not associated with increased risk of colorectal cancer, however these patients may have a shorter time interval from IBD diagnosis to development of colorectal cancer than their younger counterparts. When considering surveillance colonoscopy in elderly patients however, one must take into account the potential for increased risk of complications related to colonoscopy in elderly patients. It is imperative that gastroenterologists communicate effectively with primary care providers about the guidelines and expectations for healthcare maintenance, including safety and efficacy of vaccinations and age appropriate cancer screening in their IBD patients.

References:

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