Study Compares Early Combined Immunosuppression and Conventional Treatment in Older Crohn’s Disease Patients

Understanding Inflammatory Bowel Disease

Crohn’s disease and ulcerative colitis are the primary forms of inflammatory bowel disease (IBD), a chronic condition that affects the gastrointestinal tract. Traditionally, IBD was thought to primarily affect younger individuals. However, recent studies indicate that 10-30% of IBD patients are over the age of 60, either developing the disease later in life or aging with it.

Conventional Treatment Versus Early Combined Immunosuppression

The management of Crohn’s disease aims to achieve three key objectives: inducing and maintaining remission, enhancing the quality of life, and preventing complications to reduce adverse events. The standard treatment regimen generally involves corticosteroids. While this approach can alleviate symptoms, prolonged use often leads to resistance or dependency on these medications, increasing the risk of mortality.

An alternative treatment strategy involves combined immunosuppressive therapy that incorporates biologic agents, such as anti-tumor necrosis factor (anti-TNF), alongside immunosuppressive agents like thiopurines.

Challenges in Diagnosing and Treating Older Crohn’s Disease Patients

Numerous studies highlight the complexities involved in managing Crohn’s disease among older adults. Diagnosis can be particularly challenging due to age-related physical changes, existing comorbidities, and atypical disease presentations.

The risk of adverse events also limits treatment options for older patients. The presence of multiple comorbidities complicates therapy, and the use of multiple medications increases the likelihood of drug interactions and non-compliance. Furthermore, the lack of efficacy trials for drugs in older adults restricts physicians’ ability to explore diverse treatment options.

Aggressive Therapy for Younger Patients

In younger patients at risk of complications from Crohn’s disease, healthcare providers often employ a combination of biologics and anti-metabolites as part of an aggressive treatment strategy. However, the safety and efficacy of such aggressive therapies in older populations remain unproven, leading to a preference for conventional corticosteroid treatment in this demographic.

New Study Evaluates Safety and Effectiveness of Combined Immunosuppression in Older Patients

A recent study conducted by researchers at the University of California San Diego focused on comparing early combined immunosuppression with conventional treatment in older Crohn’s disease patients. This research was a post hoc analysis of the randomized evaluation for Crohn’s treatment (REACT) trial, with findings published in the journal Alimentary Pharmacology & Therapeutics.

The trial included 1,981 patients, 311 of whom were aged 60 years or older. Researchers assessed the impact of age on the risk of adverse events in relation to early combined immunosuppression versus conventional management. A total of 173 patients were assigned to early combined therapy, while 138 received conventional treatment. Patients who did not achieve clinical remission within 4 to 12 weeks of conventional treatment were transitioned to combined therapy involving anti-TNF and an antimetabolite.

Findings on Adverse Events and Treatment Outcomes

The study monitored adverse events such as Crohn’s disease-related hospitalizations, surgeries, and other complications over a 24-month follow-up period. Results indicated that 10% of older patients experienced complications, with 6.4% in the combined treatment group and 14.5% in the conventional group.

Moreover, the study found no significant difference in the effectiveness of early combined treatment between older and younger patients. Side effects did not increase among older patients. Although a higher number of older patients succumbed to Crohn’s disease compared to their younger counterparts, mortality rates showed no significant difference between the two treatment groups among older patients.

Implications and Strengths of the Study

One of the study’s major strengths is its post hoc analysis of a cluster randomized trial, which broadens the applicability of the findings. Additionally, the extended follow-up period enabled researchers to effectively assess the risk of complications related to Crohn’s disease. However, the study also faced limitations, including its exploratory nature, the comparison of treatment strategies rather than specific medications, and the failure to evaluate long-term effectiveness and safety comprehensively.

Conclusions on Early Combined Immunosuppression for Older Patients

The analysis suggests that early combined immunosuppression therapy based on anti-TNF is as safe and effective for older patients as it is for younger ones. This treatment approach may provide a viable alternative to the chronic use of corticosteroids for older individuals. The researchers recommend that future studies focus on identifying optimal treatment strategies for older patients at high risk for Crohn’s disease complications.

Written by Preeti Paul, MS Biochemistry
Reference: Sidharth Singh et al., Early combined immunosuppression may be effective and safe in older patients with Crohn’s disease: post hoc analysis of REACT. Aliment Pharmacol Ther. 2019;1-7. DOI:10.1111/apt.15214