AGA Issues Clinical Practice Update for Managing IBD Among Older Patients

The American Gastroenterological Association (AGA) published a clinical practice update for management of inflammatory bowel disease (IBD) among elderly patients in the latest edition of the journal Gastroenterology.

Lead author Ashwin Ananthakrishnan, MD, and colleagues noted that as many as 15% of cases of IBD among patients aged 60 years and older are diagnosed in Asia and North America, and that the prevalence of IBD in this demographic is rising by 5% per year.

The authors also stated that “care of elderly IBD patients poses unique challenges with respect to diagnosis and therapeutic decision-making.” Older patients tend to have more comorbidities, are more likely to experience complications of surgery, are at heightened risk of infection and malignancies when exposed to some therapeutic agents, and for patients with Crohn disease, also show a higher rate of mortality.

To diagnose IBD among older patients, the authors recommend colonoscopy for those with chronic diarrhea or hematochezia, and in cases in which the clinician has a moderate to high suspicion that the patient may have IBD or colonic neoplasia. When suspicion of IBD is low, the investigators suggest that biomarkers, including fecal calprotectin and lactoferrin, be checked before proceeding with endoscopy.

The clinical practice update offers 10 best practice statements that address the issues of age, functional status, comorbidities, and patient preferences and goals when developing treatment plans for elderly patients with IBD.

Certain therapeutic agents, such as systemic corticosteroids, thiopurines, and some biologics, are associated with higher risks of infection and/or malignancies, the update notes. The authors suggest the use of nonsystemic corticosteroids, such as budesonide, where appropriate rather than systemic steroids. Ustekinumab or vedolizumab, which are not associated with greater risk of malignancy, may be preferable to anti-tumor necrosis factor agents. While thiopurines are relatively inexpensive, orally administered, and have demonstrated success in maintaining remission of IBD, their use requires ongoing monitoring, and they are associated with increased risk of certain cancers.

The authors also recommended that elderly patients with IBD receive immunizations against herpes zoster, pneumococcus, and influenza before they begin treatment with any immune-suppressing medications.

Dr Ananthakrishnan and his coauthors further advise that all elderly patients receive multidisciplinary care by a team of gastroenterologists, primary care providers, nutritionists, therapists, and other health care providers as needed.

The US Preventive Services Task Force recommends that screening colonoscopy for colorectal cancer be stopped at age 75 years. The authors of the clinical update suggest that before screening ceases, patient-specific factors should be considered, including surgical candidacy, frailty, comorbidities, age, and life expectancy, among others.

—Rebecca Mashaw

Reference:

Ananthakrishnan AN, Nguyen GC, Bernstein CN. AGA clinical practice update on management of inflammatory bowel disease in elderly patients: expert review. Gastroenterology. 2021;60(1):445-451. doi:10.1053/j.gastro.2020.08.060.