San Diego, CA—Combined immunosuppressive medications have shown significant success in treating younger patients with Crohn’s disease, but clinicians have sometimes been hesitant using the agents in older patients because of safety concerns.

Now, a new study in Alimentary Pharmacology & Therapeutics advises that older patients can be safely and effectively treated with such combined immunosuppression as well.

“It is important to treat aggressive Crohn’s disease appropriately regardless of age,” said lead author Siddharth Singh, MD, of the University of California San Diego. “This may include early step-up combination therapy of tumor necrosis factor-alpha antagonists with thiopurines, which is effective and safe even in older patients, rather than treating these patients with chronic or repeated courses of corticosteroids.”

Background information in the article notes that 10% to 30% of patients with inflammatory bowel disease, of which Crohn’s is a type, are older than age 60 years. Yet the perceived risk of treatment-related complications holds physicians back from prescribing combined immunosuppression in older patients with Crohn’s, it adds.

Researchers sought to evaluate the effect of age on risk of Crohn’s disease–related complications in patients treated with early combined immunosuppression versus conventional management in a post hoc analysis of the randomized evaluation of an algorithm for Crohn’s treatment.

Compared in patients younger than age 60 years versus those age 60 years and older were efficacy, defined as time to a major adverse outcome of Crohn’s disease–related surgery, hospitalization, or serious complications; corticosteroid-free clinical remission; and safety outcomes at 24 months. In the early combined immunosuppression arm, patients with failure to achieve clinical remission within 4 to 12 weeks of corticosteroid therapy were treated with a combination of tumor necrosis factor alpha antagonist plus anti-metabolite and sequentially escalated in a stepwise algorithm.

About 15% of the 1,981 patients were age 60 years and older, with 173 randomized to early combined immunosuppression and 138 to conventional management.

Results indicate that over 2 years, 10% of older patients developed Crohn’s disease–related complications—early combined immunosuppression versus conventional management: 6.4% versus 14.5%—and 14 patients died, 3.5% combined immunosuppression versus 5.8% conventional management.

No difference between younger and older patients was detected in:
• Risk of achieving corticosteroid-free clinical remission (age <60 years, early combined immunosuppression [72.6%] vs. conventional management [64.4%]: relative risk [RR], 1.06 [95% CI, 0.98-1.15] vs. age ≥60 years, early combined immunosuppression [74.8%] vs. conventional management [63.0%]: RR, 1.09 [0.90-1.33], P-interaction = .78), or
• Time to major adverse outcome (age <60 years: hazard ratio [HR], 0.71 [0.53-0.96] vs. age ≥60 years: HR, 0.69 [0.31-1.51], P-interaction = .92) with early combined immunosuppression versus conventional management.

“We observed no difference in efficacy and safety of early combined immunosuppression compared to conventional management in older and younger patients,” study authors concluded. “Early combined immunosuppression may be considered as a treatment option in selected older patients with Crohn’s disease with suboptimal disease control.”

 « Click here to return to Weekly News Update.