Elderly-onset inflammatory bowel disease has distinct disease characteristics and treatment patterns

Inflammatory bowel disease (IBD) in older adults: An often underestimated challenge

The prevalence of inflammatory bowel disease (IBD) among older adults (> 60 years) is steadily increasing. 
It is estimated that by 2030, approximately one-third of patients treated in specialized IBD practices will belong to this age group. This population includes, on the one hand, patients with longstanding IBD diagnosed in childhood or adulthood who often experience chronic and complex disease courses. On the other hand, IBD is newly diagnosed in approximately 5% of patients older than 60 years, a condition referred to as elderly onset IBD (EO-IBD). The treatment of older patients with IBD is obviously challenging because of increased risks of infection, higher rates of adverse events related to immunosuppressive therapies, frequent comorbidities, and potential drug interactions due to polypharmacy. 
Many aspects of caring for aging IBD patients were recently summarized in an excellent review (Singh et al., Lancet Gastro. Hepatol. 2023;8(4):368-382; doi.org/10.1016/S2468-1253(22)00358-2). It is often assumed that the disease course of EO-IBD patients may be less complicated and therefore requires less advanced therapy. However, in the cited review, the disease course in EO-IBD is by no means considered less serious than that of patients diagnosed at a younger age. Moreover, EO-IBD is associated with a higher likelihood of long-term and potentially harmful corticosteroid therapy. However, the available data on the manifestation and clinical course of EO-IBD are limited, and this subgroup is clearly underrepresented in clinical trials. 
Some of these aspects are addressed by 2 Israeli studies focusing on EO-IBD. In the evaluation of a large IBD cohort from a tertiary center, Granot et al. compared disease progression in 290 patients with EO-IBD with that in 2,068 patients with adult onset disease (ages 18–60 years). Patients with EO-IBD were significantly more likely to develop IBD in the colon (diagnosis of ulcerative colitis or Crohn’s colitis), while the risk of penetrating disease or perianal fistulas was significantly lower. Patients with EO-IBD and Crohn’s disease were significantly more likely to be treated with mesalamine, which is ineffective for Crohn’s disease. In addition, EO-IBD patients received significantly fewer prescriptions for biologics or Janus kinase inhibitors. EO-IBD patients treated with biologics were more likely to receive vedolizumab, while younger patients were more likely to be treated with tumor necrosis factor (TNF) antibodies. This study found no differences in the frequency of corticosteroid prescriptions or surgical procedures. 
In a nationwide registry study from Israel (Epi-IIRN), Ben Hur et al. evaluated outcomes in patients with EO-IBD, defined here as initial diagnosis at 65 years or older, compared with 3 matched control subjects without IBD in order to assess the impact of EO-IBD on mortality and severe complications. In this analysis of 2,162 EO-IBD patients, mortality and specific risks for pneumonia, bone fractures, sepsis, and venous thrombosis were comparable to those of controls without IBD. However, this study also revealed significant differences in IBD therapy when comparing EO-IBD patients with 11,304 IBD patients diagnosed at an earlier age. On the one hand, EO-IBD patients received treatment with thiopurines or TNF antibodies significantly less often. On the other hand, abdominal surgery was performed slightly but significantly more often, with a 1.2-fold increased risk in Crohn’s disease and a 1.5-fold increased risk in ulcerative colitis. Postoperatively, EO-IBD patients more frequently received corticosteroids, while postoperative TNF-antibody therapy was prescribed less often. The rate of repeat abdominal surgery within 3 years was also higher in EO-IBD patients (29% vs. 21%). In contrast, the risk of perianal (0.27-fold) or perianal repeat surgery was significantly lower in EO-IBD patients.
Both studies provide important information about EO-IBD. EO-IBD likely manifests more frequently in the colon, while penetrating Crohn’s disease is less common. However, the reported therapies suggest that many patients with EO-IBD receive inadequate drug therapy due to concerns about adverse effects. Therefore, it is reassuring that the risk of severe infections and mortality in EO-IBD is not increased compared to the general population. These findings support the use of TNF inhibitors in selected older patients. The availability of vedolizumab, ustekinumab, and IL-23 antibodies also offers safe and well-tolerated treatment options. However, their effectiveness in older patients should be assessed in prospective registries in order to better address the anticipated demographic shift in IBD care.