Drug Management in the Elderly IBD Patient

Abstract

Managing inflammatory bowel disease (IBD) in a world of immunomodulators and biologics is complex enough, but managing the elderly IBD patient is further confounded by multiple comorbidities, polypharmacy with drug-drug interactions, and cognitive mobility/motility disturbances. Social and insurance coverage issues also always lurk in the background. All of these factors summate into a daunting challenge for the clinician. In this review, we aim to describe important considerations when prescribing to an elderly patient with IBD, taking into account costs of medications, drug interactions, the aging body's effect on pharmacokinetics, and the effect of aging on the immune system. Adverse effects and drug-drug interactions are expounded upon in detail specific for the aging adult with IBD in an effort to assist the clinician in the decision-making process.

Epidemiology and Long-term Outcome of Inflammatory Bowel Disease Diagnosed at Elderly Age—An Increasing Distinct Entity?

“…24 Therefore, caution in drug prescription is warranted, in particular in the frail elderly population. [25][26][27] Data on the disease course of EO IBD are mainly derived from small selected referral center cohorts, some collected decades ago. [28][29][30][31][32][33][34][35][36][37][38][39] Recent population-based data from the Hungarian registry and the French EPIMAD registry suggested a somewhat milder course of IBD diagnosed at older age, yet the number of elderly patients was limited 40 or data from the corresponding adult population were lacking, 41 impeding a direct comparison.…”

Clinical characteristics of ulcerative colitis in elderly patients

“…Thiopurine (6‐mercaptopurine, azathioprine) has been proven to be effective and safe for maintaining remission in moderate to severe corticosteroid‐dependent disease in elderly UC patients, 12 , 34 , 35 and its efficacy has been reported in Asian countries. 36 …”

Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape

“…Of note, for the elderly population at risk for polypharmacy, 5-ASA has been shown to interact with Warfarin[28]. In addition, combining antacids and 5-ASA may hinder the therapeutic effects of 5-ASA[29].…”

“…Similarly to 5-ASA, there is insufficient evidence to suggest that the treatment efficacy of thiopurines in the older IBD population is different than that of the younger population. Still, studies have shown a low usage of thiopurines in the elderly population that is most likely driven by the higher risk of malignancy associated with this class of drugs[29,37]. Indeed, in their various prospective observational studies, the CESAME Study group has found that ongoing and previous exposure to thiopurines increase the risk of developing non-melanoma skin cancer, that previous exposure comes with a seven-fold increased risk of developing a myeloid disorder and that ongoing exposure increases the risk of urinary tract cancers[38-39].…”

“…Therefore, newer biologics were introduced in order to target downstream mediators of gut inflammation, such as the anti-integrins (vedolizumab) and the anti-interleukin 12-23 (ustekinumab). Based on retrospective and population-based data, biologic agents in the elderly IBD population are rarely utilized, as low as 2% in UC patients and 6% in CD patients at 5 years following date of diagnosis, compared to 7% and 20% in the adult population[2,29]. In these trials, 20%-32% were receiving maintenance prednisone, defined as a treatment duration of six months or more.…”