Crohn Disease Management Presents Challenges

Inflammatory Bowel Disease (IBD) is an umbrella term for chronic inflammatory diseases of the gastrointestinal tract, primarily Crohn disease (CD) and ulcerative colitis.

The incidence and prevalence of IBD has increased substantially over the past 20 years, affecting up to 7 million people globally.¹ Of those, about 1.6 million people in the United States live with CD.^1,2 Although most people are diagnosed before age 40, up to 17% are diagnosed at 60 years and older, and the number of older adults with IBD is expected to increase as the US population ages.^2,3

A recent analysis by the CDC looked at the Medicare Provider Analysis and Review data to estimate IBD-related hospitalization rates and outcomes in 2017 among Medicare fee-for-service beneficiaries for those 65 years and older and found the age-adjusted hospitalization rate for CD to be about 16 per 100,000 Medicare enrollees.

Although there is no cure for CD, there are therapies that can significantly reduce signs and symptoms and even bring about longterm remission. In elderly patients, there are additional considerations when treating CD, such as comorbidities, disease activity, drug interactions, and loss of organ function. Although there is low mortality directly attributed to CD, prevention of surgery and quality of life are the treatment goals for older adults.³

Risk Factors and Clinical Course

The exact cause of CD is unknown, but it is thought to be a result of uncontrolled immune response to a trigger in genetically prone individuals.³ In the past, investigators thought CD was caused by diet or stress, but those are now thought to be aggravators of an already existing disease. Other theories include a defective epithelial barrier between the body’s interior or gut lumen or a disruption in the balance between good and pathogenic gut bacteria, fungi, persistent infection by a specific unknown organism, or viruses.

Although there seems to be a genetic component, environmental factors play a role as well, especially when focusing on industrialized countries. Those in developed countries and northern climates have a high incidence of CD. Other risk factors include diet, smoking, stress, and taking nonsteroidal anti-inflammatory medications.

In CD, a stimulus triggers an inflammatory process, which affects the superficial layers of the gut mucosa during early disease and then develops into ulcers and fissures that extend deeper into the bowel wall. Inflammation then causes edema and thickening of the bowel wall, resulting in the affected muscle layers becoming hypertrophied and developing fibrosis, which leads to the development of bowel obstruction and strictures.⁴

Elderly patients typically have milder disease activity, with the most common clinical course differences being absence of perianal disease and strictures and more prominence in the colonic region.^4,5

Symptoms

Symptoms of CD usually range from mild to severe, and a person may go through periods of flare-ups as well as periods of remission. Symptoms usually develop gradually, but there are instances when they can happen suddenly without any warning.

Active disease (or flare-ups) is characterized by abdominal cramping and pain, blood in the stool, diarrhea, fatigue, fever, reduced appetite, and weight loss. Severe disease may also include symptoms of inflammation of the eyes, joints, and skin, as well as the bile ducts and liver. Flare-ups may also look different in the elderly population. For example, instead of abdominal pain, anemia, and diarrhea, aging adults are more likely to experience constipation, fever, and weight loss.^5,6

Disease Management

In those 65 years and older, along with relieving symptoms, treatment goals involve maintaining remission and preventing IBD-related emergency surgery.³ Although CD tends to produce milder symptoms in older adults, management can be complicated because of comorbidities, drug interactions, and increasing organ dysfunction.

First-line therapy for mild to moderate CD usually revolves around oral aminosalicylates, especially if CD is confined to the colon. However, adherence can be difficult, and a newer formulation with the Multi-Matrix System (MMX) formulation may be beneficial in older adults.⁵ Nephrotoxicity is also an adverse event to monitor for in older adults.⁵ For more severe flare-ups, glucocorticoid therapy can be added. The risk associated with glucocorticoids in elderly patients is because of their effects on bone loss and immune function, as these individuals are more susceptible to hyperglycemia, hypertension, hypokalemia, and mental status changes.⁵

Immune modulators such as azathioprine, mercaptopurine, and methotrexate are more effective in remission than for acute flare-ups, as it usually takes 2 to 3 months to reach the full therapeutic effect.^4,5 Biologics are usually third-line therapies for CD, and because of the clinical course in elderly individuals, the need for biologics is less than that for younger patients.^5,6 When an older adult is taking a biologic, monitoring for serious infections is important.

Optimal disease management also includes preventive care and outpatient follow-up visits to make sure that vaccinations are up to date, especially when taking immunosuppressive therapy. Some studies have demonstrated an increased risk of colorectal cancer in patients with IBD, and older adults should continue regular colorectal cancer screening.⁷

Lifestyle modifications, especially a healthy diet are important for maintaining remission.⁸ In elderly patients, it is normal to experience a change in appetite, but for patients with CD, it is important that their caloric intake not drop too low, as it can weaken the immune system and put them at risk for infections. Monitoring for nutrient deficiencies and supplementing appropriately is also important, because CD can affect nutrient absorption.^6,8

Conclusion

The management of CD is challenging, because comorbidities are common among older adults. As the population ages, it is likely that pharmacists will have more patients with CD.

Because there is no cure for CD, the goal of therapy centers around improving the patient’s quality of life, maintaining remission, and preventing hospitalization and surgery.

Joanna Lewis, PharmD, MBA, has worked in a variety of practice settings, most recently as a coordinator at Duke University Hospital in Durham, North Carolina.

REFERENCES

• GBD 2017 Inflammatory Bowel Disease Collaborators. The global, regional, and national burden of inflammatory bowel disease in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Gastroenterol Hepatol. 2020;5(1):17-30. doi: 10.1016/S2468- 1253(19)30333-4.
• Overview of Crohn’s disease. Crohn’s and Colitis Foundation website. crohnscolitisfoundation. org/what-is-crohns-disease/overview. Accessed January 20, 2020.
• Xu F, Wheaton A, Liu Y, Lu H, Greenlund KJ. Hospitalizations for inflammatory bowel disease among Medicare fee-for-service beneficiaries - United States, 1999-2017. MMWR Morb Mortal Wkly Rep. 2019 Dec 13;68(49):1134-1138. doi: 10.15585/mmwr.mm6849a2.
• Freeman H. Natural history and long-term clinical course of Crohn’s disease. World J Gastroenterol. 2014; 20(1):31-36. doi: 10.3748/wjg.v20.i1.31.
• Lin W, Chen M, Cheng-Hsin C, et al. Crohn’s disease: specific concerns in the elderly. International J Gerontology. 2016;10(3):126-130. doi: 10.1016/j. ijge.2015.11.003.
• Saygili F, Saygili S, Tenlik I, et al. Crohn’s disease in the elderly: clinical presentation and manifestations from a tertiary referral center in Turkey. North Clin Istanb. 2017;3(3):183-186. doi: 10.14744/nci.2016.35582.
• Itzkowitz SH. Colorectal cancer screening and surveillance in inflammatory bowel disease. Gastroenterology. 2010;138:738-745.
• Haskey N, Gibson D. An examination of diet for the maintenance of remission in inflammatory bowel disease. Nutrients. 2017;9(3). pii: E259. doi: 10.3390/ nu9030259.