Letter: Elderly onset inflammatory bowel disease—Treat to target approach is still warranted

Editors,

There is a relative paucity of data comparing the impact that the age of IBD onset may have on therapeutic choice, drug persistence, and need for surgery; hence we commend Nørgård and colleagues for providing Nationwide registry data to help inform these important issues.¹ The authors reported that patients with IBD diagnosed after the age of 60 were less likely to be initiated on steroid-sparing therapies within 1 and 5 years of their diagnosis compared to those diagnosed at a younger age; with lower rates of corticosteroid discontinuation at 1 and 5 years, and higher rates of surgery at 5 years. Additionally, 5-ASA initiation was lower in the elderly cohort but therapy persistence at 1 and 5 years was higher than in the adult-onset cohort. These findings suggest that elderly onset IBD patients are prescribed less therapy and have fewer adjustments. In an era of treat-to-target, and therapy escalations to meet more stringent treatment targets, the data suggest that elderly onset IBD is undertreated with medical therapy, and treatment goals are possibly focused on symptom control rather than disease remission, or concerns regarding the safety of anti-TNF and immunomodulator therapy in the elderly cohort limit their use. Elderly patients are over twice as likely to experience serious adverse events with anti-TNF therapy than those aged under 40, so it is understandable why such therapies would be avoided.²

We would be interested to learn if these trends will change with greater availability of biological agents with a more favourable safety profile, as data in this cohort were limited since follow-up finished in 2020. The vedolizumab data provided in the paper suggest increasing clinician preference since it became available. The safety of gut-specific therapy using vedolizumab is exemplified by data documenting no increased risk of infection or malignancy, and comparable efficacy across age demographics.^{3, 4} Ustekinumab has comparable safety to vedolizumab,⁵ albeit across smaller observational cohort studies. These data highlight that newer advanced therapies may be preferred in older patients where infectious or malignant complications are of greater concern.

The recent availability of small molecule advanced therapies such as janus kinase inhibitors (JAK-I) and sphingosine 1-phosphate (S1P) receptor modulators offer an additional advantage with oral administration and fast onset. However, caution should be exercised, in a cohort with a greater prevalence of cardiovascular co-morbidity, particularly in the case of JAK-I. Data extrapolated from the rheumatologic JAK-I literature, which may approximate to this population, emphasised concerns regarding increased rates of venous thromboembolism, herpes zoster infection and cardiovascular events.^{6, 7} However, whether JAK selectivity mitigates an element of these risks remains to be clarified.⁸ The S1P receptor modulator ozanimod has also demonstrated a favourable safety profile despite concerns regarding bradyarrhythmia in this cohort.⁹

Hence, we anticipate greater prescribing of advanced medical therapies supported by emerging literature for those with elderly onset IBD; age alone should not limit a treat-to-target approach.

Bridgette Andrew: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); resources (equal); software (equal); validation (equal); visualization (equal); writing – original draft (equal); writing– review and editing (equal). Ashish Srinivasan: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); supervision (equal); writing – original draft (equal); writing – review and editing (equal). Annie Zhou: Data curation (equal); formal analysis (equal); methodology (equal); project administration (equal); resources (equal); writing – original draft (equal); writing – review and editing (equal). Abhinav Vasudevan: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); supervision (equal); validation (equal); visualization (equal); writing– original draft (equal); writing – review and editing (equal).

This article is linked to Nørgård et al paper. To view this article, visit https://doi.org/10.1111/apt.17520