Disease phenotype affects treatment of late-onset inflammatory bowel disease: Analysis of a large UK cohort

BACKGROUND: The incidence of inflammatory bowel disease (IBD) in older adults is rising. Studies of late-onset (LO) (diagnosis ≥60 years of age) IBD are contradictory, with some suggesting increased use of corticosteroid and reduced use of advanced therapies. This multicenter study assessed disease phenotype and therapeutic choice in LO-IBD. METHODS: Patients recruited to the NIHR IBD BioResource with LO ulcerative colitis (UC) or Crohn's disease (CD) were compared with those with young-onset (YO) (16-39 years of age) and mid-onset (MO) (40-59 years of age) IBD. Medication use and surgeries were assessed in propensity score-matched cohorts. RESULTS: A total of 32 012 patients were studied: 16 930 UC (2247 LO) and 15 082 CD (1409 LO). LO-UC was mostly left-sided, with less isolated proctitis. LO-CD patients had less ileocolonic and perianal disease. Corticosteroid, immunomodulator, and anti-tumor necrosis factor α (anti-TNF) use was lower in LO-UC and LO-CD; however, there was no difference in time to colectomy (LO-UC) or intestinal resection (LO-CD) compared with younger patients. LO-CD patients were more likely to receive vedolizumab and ustekinumab than YO-CD (odds ratio, 0.34 [95% confidence interval, 0.18-0.61] and 0.29 [95% confidence interval, 0.09-0.76], respectively). LO patients with perianal CD were less likely to receive anti-tumor necrosis factor or undergo perianal surgery than YO and MO patients with perianal CD (all P < .01). CONCLUSIONS: LO-IBD has a distinct phenotype, with less isolated proctitis (LO-UC) and less ileocolonic and perianal CD. LO-IBD patients had lower corticosteroid, immunomodulator, and anti-tumor necrosis factor use but equivalent colectomy and intestinal resection rates. LO-CD is notable for the higher use of vedolizumab and ustekinumab, suggesting that age, comorbidity, and disease phenotype affect biologic choice in older adults. Research to understand whether differential treatment of older adults is justified is crucial.