Medical Management of Inflammatory Bowel Disease in the Elderly

The optimal management of inflammatory bowel disease (IBD) can be challenging at the best of times; however, this notion becomes more salient when treating the niche population of elderly IBD. The prevalence of IBD in elderly Canadians has almost doubled in a span of 5 years, increasing from 1/160 in 2018 to 1/88 in 2023. While the majority of IBD patients are diagnosed between 20-40 years of age, 10-15% are diagnosed at >60 years of age. Elderly-onset ulcerative colitis (UC) patients more commonly have left-sided colitis with less disease extension whereas elderly-onset Crohn’s disease (CD) patients typically exhibit an inflammatory colonic phenotype. Although elderly-onset IBD patients typically demonstrate a less aggressive natural history overall, they have a similar risk of surgery compared to their adult-onset IBD counterparts with the majority being treated with non-advanced therapies. A lack of physician knowledge and comfort level in treating elderly IBD likely contribute to patients being maintained inappropriately on long-term steroids and/or 5-aminosalicylates. The existing literature on elderly IBD often fails to differentiate between aging pediatric or adult-onset IBD patients and elderly-onset IBD patients; therefore, this article will discuss the management of both groups together. Nevertheless, it is important to note that these two groups likely have different underlying pathophysiological mechanisms driving their respective diseases which can have implications for therapeutic decisions. Unfortunately, the majority of evidence to help guide decision-making in elderly IBD is derived from retrospective analyses of real-world data or health administrative datasets, as well as post-hoc analyses of randomized controlled trials (RCTs). Drug efficacy aside, nuanced care of the elderly IBD patient involves an appreciation of frailty and comorbidity to help contextualize the risks of immunosuppressive therapy. Not only is the safety of therapies contingent upon the intrinsic immunosuppressive properties of the drug, but in addition, drug efficacy needs to be considered with respect to the effectiveness in controlling disease activity and achieving corticosteroid-free remission.