Ashwin N. Ananthakrishnan, MD, MPH, on Managing IBD in Older Adults
While most cases of inflammatory bowel disease (IBD) are diagnosed in younger individuals, the condition also develops among older individuals. And the individuals who receive an IBD diagnosis earlier in life then continue to live with the condition for many years. Managing IBD among an older patient population has a different set of challenges than managing IBD in younger individuals.
Gastroenterology Consultant caught up with Ashwin N. Ananthakrishnan, MD, MPH, the director of the Crohn’s and Colitis Center at Massachusetts General Hospital, and an associate professor of medicine at Harvard Medical School, about what gastroenterologists should consider when managing IBD in an older patient, a topic he will further discuss at the Advances in Inflammatory Bowel Diseases (AIBD) Regional Meeting in Boston.
Gastroenterology Consultant: How does IBD management differ between an older individual and younger individual?
Ashwin Ananthakrishnan: IBD management differs in older individuals in several ways. Patients who are older are more susceptible to certain therapy-related adverse events because of a higher baseline rate of malignancy and infection. They also have a number of comorbidities that can influence the safety of these medications. A common misconception about the older patient population with IBD is that they have milder disease; this is not the case. Effective therapy is still needed. However, long-term use of certain therapies, particularly high-dose steroids, should be avoided.
GASTRO CON: What should gastroenterologists keep in mind when managing a patient with IBD over time?
AA: The gastroenterologist should be aware of changing baseline risks of events as patients age. For example, rates of skin cancer are higher among older patients, making them poorer candidates for thiopurine therapy. Similarly, older individuals have higher baseline rates of lymphoma. Infection risk also increases among older patients, making it more important to protect against vaccine-preventable diseases. The risk of shingles is higher among older individuals; therefore, vaccination should be advised, and the use of tofacitinib warrants caution.
Treatment goals are also different between younger and older patients. In older patients, achievement of deep remission with endoscopic and histologic healing may be less important than managing symptoms and maintaining functional independence.
GASTRO CON: What challenges exist when trying to successfully manage an older patient with IBD?
AA: There are clinical challenges posed by age, safety, and comorbidity. There are also practical challenges. Older patients may be less able to give themselves injections or administer enema or suppository therapy. They are likely to take multiple medications, so drug interactions are important to avoid, and treatment regimens need to be simple. In addition, as most older patients are on Medicare, there are specific insurance-related issues that may make coverage for certain drugs, such as budesonide, more challenging. Since these patients are on public insurance, they would also not be eligible for most patient assistance programs, which can lead to high out-of-pocket costs.
GASTRO CON: What is the main takeaway from your session that you would like the audience to consider for their clinical practice?
AA: The main takeaway is to recognize not only the unique challenges in managing older patients with IBD, but also the importance of effective therapy, as well as disease and symptom control.
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