Handle With Care: Managing IBD in Older Patients

As the saying goes, "age is a case of mind over matter: If you don't mind, it don't matter."

But for older patients with inflammatory bowel disease (IBD) and the clinicians who treat them, it's hard to ignore the complications that aging can bring, such as comorbidities, functional limitations, and polypharmacy, said Nana Bernasko, CRNP, DNP, WHNP-BC, a nurse practitioner in the department of gastroenterology at Penn State Milton S. Hershey Medical Center in Hershey, Pa.

"We are seeing a large number of patients in our clinics that are being diagnosed later on in life," she said in an oral presentation at the annual Crohn's & Colitis Congress^®, a partnership of the Crohn's & Colitis Foundation and the American Gastroenterological Association.

Between 10% and 30% of all patients with IBD are older than 60, and roughly 10%-15% of patients with IBD are diagnosed after age 60, she said.

The diagnosis of IBD is often delayed in older patients as well, with an estimated 60% of patients initially given an incorrect or incomplete diagnosis that may lead to significant delays in the initiation of appropriate therapy, she said.

Differential diagnoses for IBD in older patients include diverticulitis, ischemic colitis, infectious colitis, and radiation colitis.

Bharati Kochar, MD, MS, from the Crohn's and Colitis Center at Massachusetts General Hospital in Boston, who was not involved in the presentation, agreed that older adults need special handling.

"The management of IBD in older adults is challenging for a number of reasons, but primarily because until very recently, we have not invested in understanding how IBD should be optimally managed at older ages," she said in an interview.

"Additionally, like in all fields, older adults with IBD are disproportionately under-represented in clinical trials, meaning that we have less rigorous data guiding the management of older adults," she added.

Clinical Presentations

Older adults tend to differ in clinical presentation, compared with younger adults, Bernasko said.

For example, among patients with Crohn's disease, rectal bleeding is a more common symptom among older adults, whereas diarrhea and weight loss are more common among younger adults.

Disease location may also differ, with more senior adults having predominantly colonic disease (L2 according to the Montreal Classification of IBD), compared with more prevalent ileocolonic disease (L3) among their more junior counterparts. And although both generations of patients have inflammatory behavior (B1) at diagnosis, younger patients have more prevalent structuring (B2) and penetrating disease (B3), Bernasko noted.

Among patients with ulcerative colitis, rectal bleeding, abdominal pain, and extraintestinal manifestations are more common among the younger set, whereas left-sided colitis is more common among older patients. In addition, extensive ulcerative colitis (E3) is more common in younger patients, compared with older patients.

Management Considerations

Kochar noted that "older adults have higher baseline risks for all adverse events – like infections, malignancies, polypharmacy, procedural complications – than younger adults, so any additional risk conferred by treatments seem amplified, but that should not mean that we should avoid effectively treating older adults. It should mean we need to invest in understanding how to best mitigate those risks."

While younger patients are sometimes on multiple medications prior to starting on IBD therapy, polypharmacy is common among the older set, who may be taking drugs for diabetes, hypertension, prostate disease, and so on.

"There's just so much going on in terms of their medical background to start off with, so many medications, and then we're adding more things to it," Bernasko said.

She echoed Kochar in noting that older patients as a subgroup are under-represented in clinical trials, making it difficult to know what treatment approaches may work best for them.

In addition, older patients are at higher risk for malignancies, and for complications from surgery.

Medication adherence in older patients is frequently compromised by memory issues, she added, noting that "I can't tell you enough how sometimes our older patients forget to take their medications."

Other challenges for the management of older patients with IBD included psychosocial issues, cognitive decline, and malnutrition.

Medications and Adverse Events

Bernasko also discussed specific medications and potential adverse events and drug interactions in older patients.

For example, aminosalicylic acids (5-ASA) are associated with higher risk for nephrotoxicity and pancreatitis in older patients and can interact with thiopurines to cause leukopenia.

Steroids are associated with elevated risk for osteopenia, myopathy, cataracts, glaucoma, diabetes, and hypertension, and can interact with thiazide and loop diuretics to cause hypokalemia.

Methotrexate use in this population is linked to pancytopenia and hepatotoxicity, and it can interact with NSAIDs and multiple antibiotics to cause decreased renal secretion.

Thiopurines in older patients are associated with increased risk for leukopenia, myelosuppression, non-Hodgkin lymphoma, skin cancer, pancreatitis, and hepatotoxicity, and drugs in this class interact with allopurinol and angiotensin-converting enzyme inhibitors to increase risk for myelosuppression. Additionally, warfarin can inhibit the efficacy of thiopurines, and when these drugs are used in combination with tumor necrosis factor (TNF)–alpha inhibitors they can further increase risk of malignancy through immunosuppression.

Cyclosporine is associated with worsening hypertension and renal insufficiency among older patients.

TNF-alpha inhibitors are associated with increased risk for tuberculosis; hepatitis B; and fungal infections, malignant lymphoma, and New York Heart Association class 3 or 4 heart failure.

Ciprofloxacin in older patients with IBD has been linked to tendinopathy and increased risk for Clostridioides difficile infections. Metronidazole increases the likelihood of peripheral neuropathy in these patients.

Colon Cancer Screening

"When it comes to colon cancer screening, definitely assess the risk prior to doing this," Bernasko recommended. "Weigh all the risks and benefits. Why are we doing this for these elderly patients, because there are definitely risks associated with this."

Older patients with IBD may have difficulty with bowel prep and are at elevated risk, compared with younger patients, for cardiopulmonary complications, perforation, adverse events from sedation, and procedural complications, she cautioned.

"When it comes to our elderly patients, you want to focus on a more personalized approach – not all older people present the same way in terms of comorbidities or medications," Bernasko advised in her summary.

Editor's note: This story originally credited the opening quote to baseball legend Leroy "Satchel" Paige, but some sources say that Mark Twain was the person who said it. We've removed the reference.

Bernasko and Kochar reported having no relevant conflicts of interest to disclose. Kochar is a member of the board of editors for GI & Hepatology News.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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