Older Adults With IBD Often Undertreated
MAUI, Hawaii - Patients with inflammatory bowel disease (IBD) who are older than 65 years do not always receive the most advanced medications and are often undertreated, said Christina Ha, MD, from the Inflammatory Bowel Disease Center at Cedars-Sinai in Los Angeles.
Clinicians sometimes fall back on steroids because they are typically inexpensive and because there are fears that the new anti-TNF biologics can cause adverse events in older patients, Ha said here at the Gastroenterology Updates IBD Liver Disease Conference 2020.
"There are not a lot of safety data for the age group, which is not well represented in clinical trials," she explained. "We can't necessarily extrapolate data from a study of people with an average age in the 40s to someone in their 70s."
But, she emphasized, steroid use for more than 3 months is potentially inappropriate.
"If we have a patient on steroids, we should be saying which steroid-sparing strategy will be incorporated into their regimen when we start them on their course of steroids," she explained.
Ha said she gets asked frequently whether the man-made steroid budesonide, which is readily available, should be considered an acceptable alternative to prednisone.
"Steroids are not maintenance therapies," she pointed out. "One could argue that maybe someone who has symptomatic mild Crohn's disease could be kept on low doses of budesonide. But I would argue whether it is really the budesonide that's helping them or some other disease process related to polypharmacy."
There are no long-term safety or efficacy data for budesonide in patients with ulcerative colitis or Crohn's disease, she added.
Older patients with IBD have a decreased ability to handle disease activity; they have more comorbidities and a susceptibility to falls, said Ha. Early control of the disease is therefore essential.
Sarcopenia, an inherent part of aging when muscle mass decreases over time, is central to physiologic changes, which have implications for older adults with IBD, she said.
"We're learning that sarcopenia is also prevalent in our patients with moderate to severe inflammatory bowel disease," she explained. "Sarcopenia is associated with increased risk of infections, hospitalizations, and postoperative complications."
Other changes occur in the intestines as patients age, Ha reported. "Recent studies have shown that there are changes in the intestinal barrier, in terms of the junctions within the mucosal lining that increase intestinal permeability, which may help explain why some patients respond to treatments and others don't."
Physical Therapy Underused
Other treatment options, such as physical therapy, have also been underused in older patients with IBD. For example, there's often considerable pushback against doing a physical therapy assessment on a hospitalized older patient, said Ha.
Medicare covers up to 80% of those services, but referral wording is key. "They're not going to cover it for a primary diagnosis of ulcerative colitis or Crohn's," she explained. However, "they will cover it for a primary diagnosis of deconditioning with a secondary diagnoses of steroid exposure, anemia, Crohn's disease, or ulcerative colitis."
Physical therapy can improve muscle function, decrease muscle pain, potentially decrease analgesics, improve bone mass, and decrease joint pain, stress, fatigue, and debility. Fatigue is prevalent in patients with IBD, Ha explained.
Another underused resource is psychosocial assessment, she added. Although depression is not part of the aging process, it is common in those with chronic conditions.
Visits with licensed psychiatrists and clinical psychologists are covered under Medicare Part B, Ha pointed out, as are psychiatric evaluation and testing and individual and group therapy.
Older patients with IBD are often not receiving the care they need, said Uma Mahadevan, MD, a gastroenterologist at UCSF Health in San Francisco.
The need for awareness of polypharmacy, which Ha also discussed, is a concern in all older patients, but especially those with IBD, Mahadevan told Medscape Medical News. Clinicians need to be aware of the cascading effect of pharmacy, in which one drug's adverse effect leads to the prescription of another drug, with different adverse effects.
Ha gave the example of a patient with IBD who started to have diarrhea as an adverse effect of a medication. A clinician might then prescribe a medication for Clostridium difficile, but that might lead to nausea, leading to the prescription of an antinausea medicine.
A multidisciplinary team is needed to perform medication reconciliation, Ha noted.
Correcting Anemia Important for IBD
Anemia is also underidentified and undertreated in older patients with IBD, Ha said.
"Across the board with inflammatory bowel disease, we don't do a great job of being aggressive and correcting anemia. That has implications for fatigue and implications with functional status and circulating volume," she said.
In older patients, it might be that the decline in hemoglobin over time is more important to outcomes than the number itself, she said. "A hemoglobin of 8 g/dL is one thing, but if it was at 12 g/dL 6 months ago, that's a different story."
"For older patients, anemia is associated with a high incidence of cardiovascular disease, cognitive impairment, increased risks of falls and fractures, longer hospitalizations (and thus increased costs of care), increased frailty and dementia, and increased risk of mortality," Ha said. But, she pointed out, Medicare benefits do cover intravenous iron formulations.
Gastroenterology Updates IBD Liver Disease (GUILD) Conference 2020. Presented February 16, 2020.
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