Inflammatory Bowel Disease in the Elderly Steven N. Fine, MD Chief of GI, MetroWest Med Cntr Med...
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Transcript of Inflammatory Bowel Disease in the Elderly Steven N. Fine, MD Chief of GI, MetroWest Med Cntr Med...
Inflammatory Bowel Disease in the Elderly
Inflammatory Bowel Disease in the Elderly
Steven N. Fine, MD
Chief of GI, MetroWest Med Cntr
Med Director, Boston Endo Cntr
Steven N. Fine, MD
Chief of GI, MetroWest Med Cntr
Med Director, Boston Endo Cntr
IBD and agingIBD and aging
Are there differences between older and younger patients with IBD?
What are the differences? What are the similarities? How do we alter our approach to
treatment?
Are there differences between older and younger patients with IBD?
What are the differences? What are the similarities? How do we alter our approach to
treatment?
IBD and agingIBD and aging
Is there a difference between developing IBD at an advanced age versus having IBD at a young age and growing older?
Is there a difference between developing IBD at an advanced age versus having IBD at a young age and growing older?
Take Home Point #1Take Home Point #1
The onset of IBD at an advance age occurs more frequently than previously thought.
The onset of IBD at an advance age occurs more frequently than previously thought.
EpidemiologyEpidemiology
Incidence varies from 3.1-14.6 cases per 100,000 for CD and 2.2-14.3 for UC
Incidence of CD after age 60 is 3.5-4.0 per 100,000
Incidence of UC after age 60 is 4.5-8.0 per 100,000
Loftus EV. Gastroenterol Clin N Am 2002; 31:1-20
Robertson DJ. Gastroenterol Clin N Am 2001; 30:409-26
Evans PE. Aging Health 2007; 3:77-84
Incidence varies from 3.1-14.6 cases per 100,000 for CD and 2.2-14.3 for UC
Incidence of CD after age 60 is 3.5-4.0 per 100,000
Incidence of UC after age 60 is 4.5-8.0 per 100,000
Loftus EV. Gastroenterol Clin N Am 2002; 31:1-20
Robertson DJ. Gastroenterol Clin N Am 2001; 30:409-26
Evans PE. Aging Health 2007; 3:77-84
EpidemiologyEpidemiology
The onset of CD occurs after age 60 in 16% of patients (range: 7-26%)
The onset of UC occurs after age 60 in 12% of patients (range: 8-20%)
65% in 60s, 25% in 70s, 10% in 80s
Loftus EV. Gastroenterol Clin N Am 2002; 31:1-20
Robertson DJ. Gastroenterol Clin N Am 2001; 30:409-26
Evans PE. Aging Health 2007; 3:77-84
The onset of CD occurs after age 60 in 16% of patients (range: 7-26%)
The onset of UC occurs after age 60 in 12% of patients (range: 8-20%)
65% in 60s, 25% in 70s, 10% in 80s
Loftus EV. Gastroenterol Clin N Am 2002; 31:1-20
Robertson DJ. Gastroenterol Clin N Am 2001; 30:409-26
Evans PE. Aging Health 2007; 3:77-84
Take Home Point #2Take Home Point #2
The burden on the health care system from older IBD patients is rising.
The burden on the health care system from older IBD patients is rising.
Epidemiology:National Hospital Discharge
Survey
Epidemiology:National Hospital Discharge
Survey Using data from NHDS Age-specific rates of hospitalization over
consecutive 5-year periods Found more pronounced increase in rates
of hospitalization for older age group (65+)
Sonnenberg A. J Clin Gastroenterol 2009; 43:297-300
Using data from NHDS Age-specific rates of hospitalization over
consecutive 5-year periods Found more pronounced increase in rates
of hospitalization for older age group (65+)
Sonnenberg A. J Clin Gastroenterol 2009; 43:297-300
US Hospitalization: Crohn’sUS Hospitalization: Crohn’s
US Hospitalizations: UCUS Hospitalizations: UC
Take Home Point #3Take Home Point #3
IBD at an advanced age has a less aggressive natural history and a different distribution at presentation.
IBD at an advanced age has a less aggressive natural history and a different distribution at presentation.
Natural HistoryNatural History
Northern France, EPIMAD Registry 1988-2006; 6 million people; 9.3% of pop 3 Academic and 27 Regional Hospitals 262 Gastroenterologists Largest population-based study of elderly-
onset IBD reported to date.
Charpentier C. Gut 2014; 63:423-432.
Northern France, EPIMAD Registry 1988-2006; 6 million people; 9.3% of pop 3 Academic and 27 Regional Hospitals 262 Gastroenterologists Largest population-based study of elderly-
onset IBD reported to date.
Charpentier C. Gut 2014; 63:423-432.
IBD and age: Northern France Study
IBD and age: Northern France Study
IBD and age: distribution at presentation
IBD and age: distribution at presentation
IBD and age: Natural HistoryIBD and age: Natural History
For Crohn’s: disease extension in 31% for <17 years vs 8% for >60 years
For Ulcerative Colitis: disease extension in 49% for <17 years vs 16% for >60 years
Charpentier C. Gut 2014; 63:423-432
For Crohn’s: disease extension in 31% for <17 years vs 8% for >60 years
For Ulcerative Colitis: disease extension in 49% for <17 years vs 16% for >60 years
Charpentier C. Gut 2014; 63:423-432
Long-Term Course of Crohn’s Disease
Long-Term Course of Crohn’s Disease
Cosnes J et al. Inflammatory Bowel Disease. 2002;8:244–250.These data precede biologic therapy for Crohn’s disease
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10
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60
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Cum
ulat
ive
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(%)
Months
Penetrating
StricturingInflammatory
N = 2002 patients with Crohn’s disease since diagnosis of the disease
Probability of remaining FREE of complications
Clinical CourseClinical Course
Northern France StudyNorthern France Study
Conclusion: “Clinical course is mild in elderly-onset IBD patients. This information would need to be taken into account by physicians when therapeutic strategies are established.”
Charpentier C. Gut 2014; 63:423-432
Conclusion: “Clinical course is mild in elderly-onset IBD patients. This information would need to be taken into account by physicians when therapeutic strategies are established.”
Charpentier C. Gut 2014; 63:423-432
CD diagnosed at a young age:Natural History
CD diagnosed at a young age:Natural History
No difference in activity 3 years after dx compared with 20 years after dx
24% of Crohn’s patients had active disease 20 years later
48% in remission on treatment 28% in remission off treatment Crohn’s Disease does not “burn out”
Etienney I. Gastroenterol Clin Biol 2004; 28: 1233-9
No difference in activity 3 years after dx compared with 20 years after dx
24% of Crohn’s patients had active disease 20 years later
48% in remission on treatment 28% in remission off treatment Crohn’s Disease does not “burn out”
Etienney I. Gastroenterol Clin Biol 2004; 28: 1233-9
IBD at advanced ageIBD at advanced age
Relapses less likely Fewer post-surgical recurrence 1st episode of UC more fulminant and more likely to
require surgery Acute abdomen more common in CD Lower frequency of FHx of IBD
Wagtmans MJ. J Clin Gastroenterol 1998; 27:129-33Harper PC. Arch Int Med 1986; 146: 753-5
Softley A. Scand J Gastroenterol 1988; 23:27-30Triantafillidis JK. Digest Liver Dis 2000; 32:498-503Polito JM. Gastroenterology 1996; 111:580-6
Relapses less likely Fewer post-surgical recurrence 1st episode of UC more fulminant and more likely to
require surgery Acute abdomen more common in CD Lower frequency of FHx of IBD
Wagtmans MJ. J Clin Gastroenterol 1998; 27:129-33Harper PC. Arch Int Med 1986; 146: 753-5
Softley A. Scand J Gastroenterol 1988; 23:27-30Triantafillidis JK. Digest Liver Dis 2000; 32:498-503Polito JM. Gastroenterology 1996; 111:580-6
IBD at advanced ageIBD at advanced age
Colonic involvement is more likely Overall less risk for surgery Less risk for progression Less fistulizing disease
Gisbert JP. Aliment Pharmacol Ther 2014; 1-19
Ha C. Curr Gastroenterol Rep 2013; 15: 310 (1-9)
Colonic involvement is more likely Overall less risk for surgery Less risk for progression Less fistulizing disease
Gisbert JP. Aliment Pharmacol Ther 2014; 1-19
Ha C. Curr Gastroenterol Rep 2013; 15: 310 (1-9)
IBD and the Elderly:Mortality
IBD and the Elderly:Mortality
Prospective study 20 geographic areas in 12 European
countries 2201 IBD patients 10 year clinical follow up
Wolters FL. Gut 2006; 55:510-8
Prospective study 20 geographic areas in 12 European
countries 2201 IBD patients 10 year clinical follow up
Wolters FL. Gut 2006; 55:510-8
IBD and the Elderly:Mortality
IBD and the Elderly:Mortality
Increased mortality risk in patients with Crohn’s Disease
10 years after diagnosis Above 40 years at diagnosis was the sole factor
associated with increased mortality
Wolters FL. Gut 2006; 55:510-8
Increased mortality risk in patients with Crohn’s Disease
10 years after diagnosis Above 40 years at diagnosis was the sole factor
associated with increased mortality
Wolters FL. Gut 2006; 55:510-8
IBD and the Elderly:Mortality
IBD and the Elderly:Mortality
Age is an independent predictor of mortality in IBD inpatients
Malnutrition, male sex, need for surgery were factors associated with higher risk
In IBD, elderly age predictive of mortality with an odds ratio of 3.91
Ananthakrishnan A. Dig Dis 2009; 27: 327-34
Ananthakrishnan A. Inflamm Bowel Dis 2009; 15: 182-9
Age is an independent predictor of mortality in IBD inpatients
Malnutrition, male sex, need for surgery were factors associated with higher risk
In IBD, elderly age predictive of mortality with an odds ratio of 3.91
Ananthakrishnan A. Dig Dis 2009; 27: 327-34
Ananthakrishnan A. Inflamm Bowel Dis 2009; 15: 182-9
Take Home Point #4Take Home Point #4
Comorbidities and polypharmacy affect outcome, morbitity and mortality.
Katz S. Inflamm Bowel Dis 2013; 19: 225772.
Ha C. Curr Gastroenterol Rep 2013; 15: 310 (1-9).
Kaplan GG. Arch Surg 2011; 146: 959-964.
Comorbidities and polypharmacy affect outcome, morbitity and mortality.
Katz S. Inflamm Bowel Dis 2013; 19: 225772.
Ha C. Curr Gastroenterol Rep 2013; 15: 310 (1-9).
Kaplan GG. Arch Surg 2011; 146: 959-964.
Comorbid ConditionsComorbid Conditions
CAD 33.8% CLD 22.6% CHF 22.6% PVD 7.4% CVD 12.5% PUD/GIB 17.8% Mod-sev Liver 10.7%
CAD 33.8% CLD 22.6% CHF 22.6% PVD 7.4% CVD 12.5% PUD/GIB 17.8% Mod-sev Liver 10.7%
DM 18.8% DM and end-org 9.4% CVA 12.5% Mod to sev RD 11.5% Rheum 10.2 % Dementia 2.5% HIV 0.5%
DM 18.8% DM and end-org 9.4% CVA 12.5% Mod to sev RD 11.5% Rheum 10.2 % Dementia 2.5% HIV 0.5%
PolypharmacyPolypharmacy
128 IBD pts greater than 65 yo Average of 9.5 routine medications >10 meds (severe polypharmacy)
associated with comorbidity scores and steroid use
80% of pts had at least one medication interaction, 63% involved IBD therapy.
Parian AM. DDW 2013: Su1130
128 IBD pts greater than 65 yo Average of 9.5 routine medications >10 meds (severe polypharmacy)
associated with comorbidity scores and steroid use
80% of pts had at least one medication interaction, 63% involved IBD therapy.
Parian AM. DDW 2013: Su1130
Clinical CourseClinical Course
Take Home Point #5Take Home Point #5
Look for, prophylax for, and treat C.difficile and venous thromboembolism.
Look for, prophylax for, and treat C.difficile and venous thromboembolism.
Risk Factors for Osteoporosis in IBD
Risk Factors for Osteoporosis in IBD
Medications Advanced age Low body mass Reduced physical activity Family History of Osteoporosis TOB
Ali T. Am J Med 2009; 122: 599-604
Medications Advanced age Low body mass Reduced physical activity Family History of Osteoporosis TOB
Ali T. Am J Med 2009; 122: 599-604
AGA Recommendationsfor Managing Osteoporosis
AGA Recommendationsfor Managing Osteoporosis
IBD patient:Any of:-Prolonged steroid use(>3mo consec or recurrent courses)-Low trauma, fragility fracture-Postmenopausal or male age >50-Hypogonadism
DXA
T score >-1
Basic Prevention:-Ca/Vit D-exercise-smoking cessation-avoid alcohol-minimize corticosteroids-treat hypogonadismT score -2.5 to -1
Prevention and:-repeat DXA 2 years-Prolonged CS consider BP and DXA 1 year
T score <-2.5
Vert FractureRegardless of DXA
Prevention and:-Screen other causes low BMD-Bisphosphonate therapy or-Refer to bone specialist
Gastroenterology 2003;124:795-841
Adherence to GuidelinesAdherence to Guidelines
Survey 1000 AGA members 304 responders; 258 appropriate 49% utilized guidelines
Wagnon J. Inflam Bowel Dis 2009; 15: 1082-1089
Survey 1000 AGA members 304 responders; 258 appropriate 49% utilized guidelines
Wagnon J. Inflam Bowel Dis 2009; 15: 1082-1089
Reasons for Non-UtilizationReasons for Non-Utilization
Adherence to GuidelinesAdherence to Guidelines
Retrospective study George Washington University 26.5% had DEXA 13.7% had vitamin D testing
Less than half ordered by GI MDs 35.7% had vitamin D deficiency
Bakshi A. Am J Gastroenterol 2009; 104: 791.
Retrospective study George Washington University 26.5% had DEXA 13.7% had vitamin D testing
Less than half ordered by GI MDs 35.7% had vitamin D deficiency
Bakshi A. Am J Gastroenterol 2009; 104: 791.
Adherence to GuidelinesAdherence to Guidelines
Retrospective George Washington University Men with IBD 9% had vitamin D testing 21.5% had DEXA
65% had either osteoporosis or osteopenia
Nguyen HD. Am J Meds Health 2010; 4: 71-4.
Retrospective George Washington University Men with IBD 9% had vitamin D testing 21.5% had DEXA
65% had either osteoporosis or osteopenia
Nguyen HD. Am J Meds Health 2010; 4: 71-4.
Take Home Point #6Take Home Point #6
IBD patients over age 50 should have Bone Density Testing and then follow-up depending on results (follow the guidelines)
IBD patients over age 50 should have Bone Density Testing and then follow-up depending on results (follow the guidelines)
IBD and the Elderly:Surgery
IBD and the Elderly:Surgery
Rate of early surgery for fulminant disease for UC higher in elderly; after 5 years for young
Surgery for CD in elderly with higher mortality rate and complications
8-fold increase in post-op mortality (perf/sepsis) As the number of comorbidities increase, post-
operative mortality increasesGreenwald DA. Curr Treat Options in Gastro 2003; 6:213-225Almony G. Scand J Gastroenterol 2002; 37:1025-28Juneja M. Dig Dis Sci 2012; 57:2408-15Guy TS. Surg Clin North Am 2001; 81:159-168Kaplan GG. Arch Surg 2011; 146: 959-964
Rate of early surgery for fulminant disease for UC higher in elderly; after 5 years for young
Surgery for CD in elderly with higher mortality rate and complications
8-fold increase in post-op mortality (perf/sepsis) As the number of comorbidities increase, post-
operative mortality increasesGreenwald DA. Curr Treat Options in Gastro 2003; 6:213-225Almony G. Scand J Gastroenterol 2002; 37:1025-28Juneja M. Dig Dis Sci 2012; 57:2408-15Guy TS. Surg Clin North Am 2001; 81:159-168Kaplan GG. Arch Surg 2011; 146: 959-964
IBD in the Elderly: Surgical Outcomes
IBD in the Elderly: Surgical Outcomes
Medical College of Wisconsin IBD surgeries in patients after 65 yo Compared with 3 control groups: 18-35 yo, 36-49
yo, 50-64 yo No difference in complication rate. Comorbidity Index and nutritional status are risk
factors.
Bautista MC. Dig Dis Sci 2013; 58:2955-62
Medical College of Wisconsin IBD surgeries in patients after 65 yo Compared with 3 control groups: 18-35 yo, 36-49
yo, 50-64 yo No difference in complication rate. Comorbidity Index and nutritional status are risk
factors.
Bautista MC. Dig Dis Sci 2013; 58:2955-62
IBD and the Elderly:Ileal Pouch-Anal Anastomosis
IBD and the Elderly:Ileal Pouch-Anal Anastomosis
Mayo Clinic 2002 pts IPAA for UC or FAP Over a 9 year period Question: does age affect surgical
outcome?
Chapman JR. Arch Surg 2005; 140:534-40
Mayo Clinic 2002 pts IPAA for UC or FAP Over a 9 year period Question: does age affect surgical
outcome?
Chapman JR. Arch Surg 2005; 140:534-40
IBD and the Elderly:Ileal Pouch-Anal Anastomosis
IBD and the Elderly:Ileal Pouch-Anal Anastomosis
No increase in pouch failure in the elderly Increase in incontinence No difference in quality of life
Chapman JR. Arch Surg 2005; 140:534-40
No increase in pouch failure in the elderly Increase in incontinence No difference in quality of life
Chapman JR. Arch Surg 2005; 140:534-40
Take Home Point #7Take Home Point #7
There is less tendency for surgery in the elderly, but worse outcomes; and comorbid conditions and nutritional status are risk factors for poor surgical outcomes.
There is less tendency for surgery in the elderly, but worse outcomes; and comorbid conditions and nutritional status are risk factors for poor surgical outcomes.
Fit Elderly and Frail ElderlyFit Elderly and Frail Elderly
concept for individualizing therapy walker, wheelchair, falls, polypharmacy,
comorbidities, oxygen, cognitive function, level of activity help to define risk.
guide therapeutic decisions. no scientific studies.
Katz S. Inflamm Bowel Dis 2013; 19: 2257-72
Katz S. Gastroenterol & Hep 2008; 4: 337-47
concept for individualizing therapy walker, wheelchair, falls, polypharmacy,
comorbidities, oxygen, cognitive function, level of activity help to define risk.
guide therapeutic decisions. no scientific studies.
Katz S. Inflamm Bowel Dis 2013; 19: 2257-72
Katz S. Gastroenterol & Hep 2008; 4: 337-47
IBD and the Elderly:5-ASA
IBD and the Elderly:5-ASA
More attention may be needed for patients with chronic renal insufficiency and 5-ASA
Exacerbations of the IBD may increase risk due to dehydration and pre-renal state
Half-life is increased in elderly Interactions with warfarin and 6MP/AZA
Katz S. Inflamm Bowel Dis 2013; 19: 2257-72
Gisbert JP. Inflamm Bowel Dis 2007; 13:629-38
Katz S. Gastroenterol & Hep 2008; 4:337-47
More attention may be needed for patients with chronic renal insufficiency and 5-ASA
Exacerbations of the IBD may increase risk due to dehydration and pre-renal state
Half-life is increased in elderly Interactions with warfarin and 6MP/AZA
Katz S. Inflamm Bowel Dis 2013; 19: 2257-72
Gisbert JP. Inflamm Bowel Dis 2007; 13:629-38
Katz S. Gastroenterol & Hep 2008; 4:337-47
IBD and the ElderlyAntibiotics
IBD and the ElderlyAntibiotics
Neuropathic effects of metronidazole Effects on warfarin Cdifficile
Greenwald DA. Curr Treat Option Gastroenterol 2003; 6:213-25
Katz S. Gastroenterol & Hep 2008; 4:337-47
Katz S. Inflamm Bowel Dis 2013; 19: 2257-72
Neuropathic effects of metronidazole Effects on warfarin Cdifficile
Greenwald DA. Curr Treat Option Gastroenterol 2003; 6:213-25
Katz S. Gastroenterol & Hep 2008; 4:337-47
Katz S. Inflamm Bowel Dis 2013; 19: 2257-72
IBD and the Elderly:Steroids
IBD and the Elderly:Steroids
Infection Osteoporosis Mental status Depression HTN DM
Katz S. Gastroenterol & Hep 2008; 4: 337-47
Infection Osteoporosis Mental status Depression HTN DM
Katz S. Gastroenterol & Hep 2008; 4: 337-47
Hypertension Hypokalemia Hyperglycemia Osteonecrosis CHF Consider budesonide
Hypertension Hypokalemia Hyperglycemia Osteonecrosis CHF Consider budesonide
IBD and the Elderly:Methotrexate
IBD and the Elderly:Methotrexate
Decrease in GFR impacts on drug clearance Effects on warfarin May increase atherosclerosis and
cardiovascular mortality by increasing levels of homocysteine
Increase risk of osteoporosisKatz S. Inflamm Bowel Dis 2013; 19: 2257-72
Landewe RBM. Lancet 2000; 355:1616-7
Greenwald DA. Curr Treat Options Gastro 2003; 6:213-225
Decrease in GFR impacts on drug clearance Effects on warfarin May increase atherosclerosis and
cardiovascular mortality by increasing levels of homocysteine
Increase risk of osteoporosisKatz S. Inflamm Bowel Dis 2013; 19: 2257-72
Landewe RBM. Lancet 2000; 355:1616-7
Greenwald DA. Curr Treat Options Gastro 2003; 6:213-225
IBD and the Elderly:6MP/Azathioprine
IBD and the Elderly:6MP/Azathioprine
Myelosuppression is unrelated to age Significant dose reduction if used with
allopurinol; inhibit warfarin effect Use TPMT enzyme activity and Thiopurine
metabolites to guide therapy MTX to avoid risk of Lymphoma/Skin CaPresent DH. Ann Int Med 1989; 111:641-9 Connell WR. Gut 1993; 34:1981-5
O’Brien JJ. Gastroenterology 1991; 101:39-46
Myelosuppression is unrelated to age Significant dose reduction if used with
allopurinol; inhibit warfarin effect Use TPMT enzyme activity and Thiopurine
metabolites to guide therapy MTX to avoid risk of Lymphoma/Skin CaPresent DH. Ann Int Med 1989; 111:641-9 Connell WR. Gut 1993; 34:1981-5
O’Brien JJ. Gastroenterology 1991; 101:39-46
Take Home Point #8Take Home Point #8
6MP/AZA pose a significant risk of lymphoproliferative disorders in the elderly, so methotrexate may be a better option.
6MP/AZA pose a significant risk of lymphoproliferative disorders in the elderly, so methotrexate may be a better option.
IBD and the Elderly:Anti-TNFs
IBD and the Elderly:Anti-TNFs
Evaluated the safety of infliximab in older pts (70 yo)
Used infliximab withdrawal and the reason for withdrawal as outcome
9 hospitals around Burgundy, France 83 pts (RA and AS)
Chevillotte-Maillard H. Rheumatology 2005; 44:696-7
Evaluated the safety of infliximab in older pts (70 yo)
Used infliximab withdrawal and the reason for withdrawal as outcome
9 hospitals around Burgundy, France 83 pts (RA and AS)
Chevillotte-Maillard H. Rheumatology 2005; 44:696-7
IBD and the Elderly:Anti-TNFs
IBD and the Elderly:Anti-TNFs
IBD and the Elderly:Anti-TNFs
IBD and the Elderly:Anti-TNFs
Northern Ireland 94 patients Severe inflammatory arthritis Mean age of pts with major infections was
65 yo
Cairns AP. The Ulster Medical Journal 2002; 71: 101-5
Northern Ireland 94 patients Severe inflammatory arthritis Mean age of pts with major infections was
65 yo
Cairns AP. The Ulster Medical Journal 2002; 71: 101-5
IBD and the Elderly:Anti-TNFs
IBD and the Elderly:Anti-TNFs
Mayo Clinic experience 500 patients; Crohn’s Disease 1% mortality 3 of the 5 attributable deaths were
associated with “relatively old age” and “severe comorbidities”
Colombel J. Gastroenterlogy 2004;126:19-31
Mayo Clinic experience 500 patients; Crohn’s Disease 1% mortality 3 of the 5 attributable deaths were
associated with “relatively old age” and “severe comorbidities”
Colombel J. Gastroenterlogy 2004;126:19-31
Take Home Point #9Take Home Point #9
Anti-TNFs have a lower efficacy and a higher risk in the elderly
Anti-TNFs have a lower efficacy and a higher risk in the elderly
Take Home Point #10Take Home Point #10
Step-Up Therapy is the better approach than Top-Down Therapy for elderly IBD patients.
Step-Up Therapy is the better approach than Top-Down Therapy for elderly IBD patients.
Medical TherapyMedical Therapy
Additional Thoughts/ConcernsAdditional Thoughts/Concerns
Colon Cancer Screening/Surveillance Depression Compliance Intestinal Bacteria Vaccination
Gisbert JP. Aliment Pharmacol Ther 2014; 1-19
Long MD. J Crohns Colitis 2013; 1-7
Enck P. Z Gastroenterol. 2009; 47: 653-8
Colon Cancer Screening/Surveillance Depression Compliance Intestinal Bacteria Vaccination
Gisbert JP. Aliment Pharmacol Ther 2014; 1-19
Long MD. J Crohns Colitis 2013; 1-7
Enck P. Z Gastroenterol. 2009; 47: 653-8
Conclusions: Take Home PointsConclusions: Take Home Points
The onset of IBD at an advanced age occurs more frequently than previously thought.
The burden on the healthcare system from older IBD patients is rising.
IBD at an advanced age has a less aggressive natural history and a different distribution at presentation.
The onset of IBD at an advanced age occurs more frequently than previously thought.
The burden on the healthcare system from older IBD patients is rising.
IBD at an advanced age has a less aggressive natural history and a different distribution at presentation.
Conclusions: Take Home PointsConclusions: Take Home Points
Comorbidities and polypharmacy affect outcomes, morbidity, and mortality.
Look for, prophylax for, and treat Cdifficile and venous thromboembolism.
IBD patients over age 50 should have bone density testing.
Less tendency for surg, but worse outcomes; comorbid conditions&nutritional status are RFs for poor surgical outcomes.
Comorbidities and polypharmacy affect outcomes, morbidity, and mortality.
Look for, prophylax for, and treat Cdifficile and venous thromboembolism.
IBD patients over age 50 should have bone density testing.
Less tendency for surg, but worse outcomes; comorbid conditions&nutritional status are RFs for poor surgical outcomes.
Conclusions: Take Home PointsConclusions: Take Home Points
6MP/AZA pose significant risk of lymphoproliferative disorders in the elderly, so methotrexate may be a better option.
Anti-TNFs have a lower efficacy and a higher risk in the elderly.
Step-Up Therapy is the better approach than Top-Down Therapy for the elderly.
6MP/AZA pose significant risk of lymphoproliferative disorders in the elderly, so methotrexate may be a better option.
Anti-TNFs have a lower efficacy and a higher risk in the elderly.
Step-Up Therapy is the better approach than Top-Down Therapy for the elderly.