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Select Patient Populations: The Elderly
Approximately 15% of IBD cases are diagnosed after 65 years of age, and with the
aging of the population, many patients are entering “the golden years” with an exist-
ing diagnosis of IBD [ 49 ]. Whether the efficacy and safety of biologic therapy
among elderly IBD is similar to young patients has not been definitively established.
There are only a few observational studies reporting anti-TNF response and remis-
sion across age groups; some studies show similar results in older and younger
patients [ 50 , 51 ], and others show that elderly patients treated with anti-TNF thera-
pies have a lower rate of short-term clinical response and a higher rate of severe
adverse events than younger patients receiving the same treatment [ 52 ]. Furthermore,
elderly patients may have a higher likelihood for discontinuation of therapy [ 53 ].
When contemplating biologic therapy for elderly patients, age-specific concerns
such as comorbidities, diminished physical and cognitive function, polypharmacy
and its consequences, and costs should all be considered. The risk of adverse events
may be significantly increased in elderly patients, especially serious infection and
malignancy, suggesting the need for careful monitoring during therapy. This moni-
toring should include routine laboratory assessments for safety, inflammatory mark-
ers to monitor disease activity, screening for osteoporosis, and age-appropriate
cancer screening for breast, colon, lung, prostate, and skin cancer [ 54 ]. In one study,
over half of elderly patients had a significant comorbidity such as cardiovascular
disease, chronic pulmonary disease, diabetes mellitus, smoking, or cancer histories.
Caution is therefore required when considering relative and absolute contraindica-
tions (including class III–IV heart failure) and assessment for drug-drug interac-
tions potentially induced by polypharmacy including supplements and
over-the-counter medications [ 55 ].
Considerations Upon Discontinuation of Biologic Therapies
There are no clear recommendations or sufficient data to guide broadly relevant
clear recommendations for the question of if and when to discontinue biologic ther-
apy. These decisions are influenced by treatment efficacy, disease state and pheno-
type, risk of future complication, patient preference, tolerability, and external patient
factors. Some suggest that discontinuation can be considered among patients in
remission for at least 1 year on biologic therapy, with careful considerations of the
benefits of continuing therapy weighed against the risks of discontinuation.
Withdrawal of therapy may be more appropriate in patients with CD who have both
complete mucosal healing and no biological evidence of inflammation [ 16 ]. A sys-
tematic review of studies looking at rates of relapse after discontinuation showed
that approximately one-third of patients with IBD flare within/after 12 months of
withdrawal of anti-TNF therapy after having achieved a sustained remission, and
this proportion increased to 50% and higher in the longer term [ 56 , 57 ]. A decision
L. Zhu and G.Y. Melmed