Clinical differences between elderly-onset ulcerative colitis and non-elderly-onset ulcerative colitis: A nationwide survey data in Japan

Surgical trend including minimally invasive surgeries for ulcerative colitis in the COSUC study: the largest multicenter cohort study in Japan

BACKGROUND

The number of patients with ulcerative colitis (UC) is increasing rapidly in Asia. No large study has evaluated the clinical outcomes of hand-sewn ileal pouch-anal anastomosis (IPAA). This study aimed to create a large database of the surgical outcomes of UC, present the trends of surgical procedures, and evaluate the impact of minimally invasive procedures on UC.

METHODS

Data of patients first treated from 2005 to 2019 were collected; two-staged surgery data were extracted, and minimally invasive surgery (MIS) and open surgery (OS) outcomes were compared using propensity-score matching.

RESULTS

The data of 1558 cases were selected as the main analysis set. The number of surgical cases of UC has been increasing, with increasing proportion of MIS cases (2005: 43%, 2019: 84%). The median age of the patients increased in these 15 years (39.5-56 years old). Of 873 patients who underwent two-staged surgery, after 3:1 matching, 408 MIS and 176 OS cases were compared. Hand-sewn anastomoses were performed in 293 MIS (72.0%) and 142 OS-IPAA (80.7%) cases. The proportion of early complications (≥ Grade 3) did not vary between the two groups. Intraoperative blood loss was lower and blood transfusions were less frequent in the MIS group.

CONCLUSIONS

The proportion of MIS for UC has rapidly increased over the past 15 years. The total number of MIS and OS complications did not vary significantly between the groups. The short-term advantages of MIS include reduced blood loss and less necessity for blood transfusions.

Real-World Effectiveness and Safety of Vedolizumab in Patients ≥ 70 Versus < 70 Years With Ulcerative Colitis: Multicenter Retrospective Study

BACKGROUND AND AIM

Vedolizumab (VDZ) is often used in older patients with ulcerative colitis (UC) in clinical practice; however, real-world evidence is still limited, including in those with late-onset UC.

METHODS

This post hoc analysis of a multicenter, retrospective, observational chart review, enrolling 370 patients with UC receiving VDZ between December 2018 and February 2020, compared effectiveness and safety of VDZ among patients ≥ 70 (n = 40) versus < 70 years (n = 330), and among patients ≥ 70 years with and without late-onset UC (age at disease onset: ≥ 70 [n = 13] versus < 70 years [n = 26]).

RESULTS

There were no differences between patients ≥ 70 and < 70 years in clinical remission rates (week 6: 57.5% vs. 47.6%, p = 0.9174; week 14: 62.5% vs. 54.8%, p = 0.1317; week 54: 47.5% vs. 46.4%, p = 0.8149), primary nonresponse (10.0% vs. 15.5%, p = 0.6248), loss of response (12.5% vs. 9.4%, p = 0.5675), or overall safety. Among patients ≥ 70 years, the incidence of adverse drug reactions was numerically greater in those with concomitant corticosteroids than in those without. For older patients with and without late-onset UC, week 54 remission rates were 23.1% versus 57.7% (p = 0.0544); surgery was reported in 3/13 versus 2/26 patients and hospitalization in 5/13 versus 6/26 patients. One death was reported in patients with late-onset UC.

CONCLUSIONS

VDZ effectiveness and safety were similar in patients ≥ 70 and < 70 years; VDZ may be a suitable treatment option for patients ≥ 70 years with UC. Patients with late-onset UC tended to have more frequent surgery/hospitalization and lower effectiveness than those without, possibly necessitating greater caution when using VDZ.

TRIAL REGISTRATION

Japanese Registry of Clinical Trials registration number: jRCT-1080225363.

Differences in Clinical Practice and Disease Course Between Elderly-Onset and Long-Standing Elderly Ulcerative Colitis: A Single-Center Study in Japan

The optimal immunosuppressive therapy for elderly patients with ulcerative colitis (UC) remains unclear. We aimed to evaluate clinical practice and prognosis in elderly patients with UC through comparing between those with elderly-onset UC (EOUC) and those with long-standing elderly UC (LEUC). In this retrospective single-center cohort study, we evaluated elderly patients with UC aged ≥ 60 in August 2022 through collecting medical record data from the time of diagnosis of UC until August 2022. The patients were divided into two groups based on age at disease onset: EOUC (age at onset, ≥ 60 years) and LEUC (age at onset, < 60 years). We assessed the cumulative rates of systemic steroid and molecular targeted drug (MTD) initiation, and colectomy. We enrolled 97 eligible patients (EOUC group, n = 30; LEUC group, n = 67). The cumulative rates of initiating systemic steroid (46% vs. 22% at 1 year, respectively; P = 0.002) and MTD (17% vs. 5% at 1 year, respectively; P = 0.002) were higher in the EOUC group than in the LEUC group. In multivariate analysis, elderly onset was significantly associated with systemic steroid (hazard ratio [HR] 2.74, 95% confidence interval [CI] 1.43-5.29; P = 0.003) and MTD (HR 2.76, 95% CI 1.30-5.87; P = 0.008) initiation. Cumulative colectomy rates did not differ significantly between the two groups. Patients with EOUC were initiated on systemic steroids and MTDs sooner following disease onset than patients with LEUC. Our findings suggest rapid progression and refractoriness in patients with EOUC.

Clinical practice and outcome of patients with elderly-onset ulcerative colitis: Insights from a nationwide claims database study in Japan

Background and Aim

The number of older patients with ulcerative colitis is increasing; however, limited data exist regarding the differences between elderly- and non-elderly-onset ulcerative colitis. We aimed to compare the clinical practice and course of elderly-onset ulcerative colitis with those of non-elderly-onset ulcerative colitis.

Methods

We selected older patients with ulcerative colitis and divided them into the elderly- and non-elderly-onset ulcerative colitis groups according to their age at onset. We compared the cumulative systemic steroid-free, molecular targeting drug-free, and surgery-free rates between the two groups. We performed a multivariate analysis to identify the clinical factors related to systemic steroid administration, the use of molecular targeting drugs, surgery, and death.

Results

We collected data of 2669 and 277 elderly and non-elderly-onset ulcerative colitis patients, respectively. The cumulative systemic steroid-free rate of elderly-onset ulcerative colitis was significantly lower than that of non-elderly-onset ulcerative colitis. However, no difference was observed in the cumulative molecular targeting drugs and surgery-free rates between the two groups. Elderly-onset ulcerative colitis significantly increased the risk of systemic steroid administration and death but not the use of molecular targeting drugs and surgery.

Conclusion

The disease severity of ulcerative colitis and clinical practice may not differ between the elderly- and non-elderly-onset groups. However, elderly-onset ulcerative colitis was associated with increased mortality risk. Thus, we need to pay attention to the patients' condition and appropriate timing of surgery for patients with elderly-onset ulcerative colitis.

Safety of full bowel preparation and colonoscopy in elderly patients with ulcerative colitis: A real-world multicenter retrospective cohort study

Background

The number of elderly patients with ulcerative colitis (UC) has been increasing worldwide. Complications are common in elderly patients who undergo colonoscopy, raising doubts about whether colonoscopy should be performed in the same way in this age group as in younger patients. The aim of this study was to determine the safety of full bowel preparation and colonoscopy in elderly patients with UC.

Methods

We retrospectively reviewed a cohort of patients with UC who had visited any of the 12 hospitals and were registered in our inflammatory bowel disease database. We compared complications associated with colonoscopy and bowel preparation and relapse of UC after colonoscopy in 133 patients aged ≥65 years with UC (the elderly group) and 116 randomly selected patients aged <65 years with UC (the non-elderly group).

Results

Nine elderly patients were not referred for colonoscopy by their physicians because of poor performance status or advanced age. There was no significant between-group difference in the complication rate (p = 0.57) or frequency of relapse of UC after colonoscopy (p = 0.67).

Conclusions

The findings of this study indicate that colonoscopy can be performed as safely in elderly patients with UC as in their younger counterparts. However, our results also indicate that colonoscopy is often avoided in elderly patients, possibly because of concerns about safety.

Impact of Concomitant Prescriptions and Lifestyle Factors on the Initial Course of Newly Diagnosed Inflammatory Bowel Disease

Introduction

There is a close relationship between the relapse of inflammatory bowel disease (IBD) and lifestyle factors, including concomitant medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), antithrombotic drugs, smoking status, and alcohol consumption. However, solid evidence is limited regarding the risk factors at diagnosis and initial disease course. This study aimed to explore the impact of concomitant prescriptions and lifestyle factors in patients with newly diagnosed IBD using a large-scale real-world database.

Methods

This is a retrospective inception cohort study using the insurance claims database. Newly diagnosed patients with UC and CD were enrolled between January 2005 and May 2020. Concomitant prescriptions and lifestyle factors were assessed for new biologics use, surgery, and hospitalization during the first year.

Results

In total, 6,743 patients with UC and 1,000 patients with CD were enrolled. Proton pump inhibitors, antithrombotics, antibiotics, and NSAIDs were identified as associated factors for both biologics use and hospitalization in UC patients (all p < 0.01), and antithrombotics were identified as associated factors for both biologics use and hospitalization in CD patients (all p < 0.01) in multivariable analyses. Interestingly, smoking was protective against hospitalization in UC patients (p < 0.01) but not in CD patients (p = 0.997), analyzed by univariate analysis. Alcohol consumption was protective against hospitalization outcomes in UC patients (p = 0.02) but not in CD patients (p = 0.27), analyzed by univariate analysis.

Conclusion

Immediate attention should be paid to concomitant medications at diagnosis because they may have impact on the initial course of IBD.

The Prognostic Nutritional Index is a Predictive Marker for Postoperative Complications in Patients with Late-Onset Ulcerative Colitis

PURPOSE

The number of patients with late-onset ulcerative colitis (UC) requiring surgery has increased in recent years. The risk of postoperative complications is higher in the elderly, so preoperative assessment is important. We aimed to explore the performance of preoperative assessment of nutritional markers for predicting postoperative complications in patients with late-onset UC.

METHODS

We retrospectively analysed 140 medically refractory UC patients who underwent surgery. The association between age at UC onset and risk of postoperative complications was explored using a fractional polynomial model. Uni- and multi-variate logistic regression analyses were performed to identify nutritional markers associated with postoperative complications.

RESULTS

The polynomial model showed patients with UC onset after 50 years of age had an increased risk of postoperative complications. Late-onset (LO) UC, an onset occurring after 50 years old, was associated with a higher risk of incisional surgical site infection (SSI) and intra-abdominal abscess than early-onset (EO) UC. Compared with the EO group, the LO group had fewer nutritional markers that were significantly associated with postoperative complications. The prognostic nutritional index (PNI) was calculated using the albumin level and the total lymphocyte count, and it was the only index that was significant in the LO group (odds ratio 0.872 95% CI 0.77-0.99, P = 0.03).

CONCLUSIONS

It was more difficult to use nutritional status to predict the risk of postoperative complications in patients with late-onset UC than in patients with early-onset ulcerative colitis. PNI may be a useful nutritional marker for patients with both late- and early-onset UC.

Management of inflammatory bowel disease in the elderly: A review

The burden of Inflammatory Bowel Disease (IBD) is increasing worldwide, with a particular increase in the prevalence in the elderly population, due to the ageing of young-onset IBD as well as to the increasing incidence in elderly patients. Elderly IBD patients present specific challenges to the treating physician, as they have comorbidities, lower functional reserves, and higher risk of treatment-related complications. The diagnosis of IBD in the elderly may be difficult due to a more subtle disease presentation and to a wide range of differential diagnosis. Moreover, as these patients are often excluded from clinical trials, there is a lack of high-quality evidence to inform on the most appropriate management. Despite an increasing prevalence, the management of IBD in the elderly is still hindered by frequent misconceptions by physicians treating these patients. Due to a erroneous notion of a milder disease course and fear of adverse events, elderly IBD-patients are managed with frequent and continuous use of steroids and undertreated with effective medical therapies. In this review, we describe the principles of management of IBD in the elderly, which is a topic of increasing importance to IBD clinics, that will have to progressively adapt to care for an ageing population.

Have advances in medical therapy for ulcerative colitis impacted surgical treatment?

Aim

The purpose of this study was to examine how the clinical characteristics, indications for surgery, and postoperative course of ulcerative colitis (UC) surgical patients changed before and after the introduction of biological agents.

Methods

Patients who underwent surgery for UC at Hyogo Medical University between 2000 and 2019 were included in the study; those who underwent surgery between 2000 and 2009 were included in the early group (n = 864), and those who underwent surgery between 2010 and 2019 were included in the late group (n = 834); each study factor was retrospectively compared.

Results

The mean ages at surgery (y) were 39.7 ± 15.1 y in the early group and 46.7 ± 17.8 y in the late group (P < .01). Antitumor necrosis factor agents were used (%) in 2 (0.2) patients in the early group and 317 (38.0) patients in the late group (P < .01). The number of cancer or dysplasia patients for whom surgery was indicated was significantly higher in the late group (11%/26%, P = .01). With regard to surgery in elderly individuals, the number of elderly patients (65 y and older) undergoing surgery was significantly higher in the late group (8.0%/18.6%, P < .01). For emergency surgery, the mortality rates were 16.7% (2/12) in the early surgery group and 15.7% (8/51) in the late surgery group (P = .61).

Conclusion

The characteristics of UC patients requiring surgery in Japan have changed. The distribution of surgical indications changed, and the number of patients with cancer and dysplasia requiring surgery increased. The prognosis of elderly patients who underwent emergency surgery was poor.

The long-term effect of biologics in patients with ulcerative colitis emerging from a large Japanese cohort

To gain a better understanding of the effects of biologics, we evaluated clinical outcomes in patients with moderate to severe exacerbations of ulcerative colitis (UC). This retrospective, multicenter study retrieved the entire clinical courses of UC patients who began treatments between 2004 and 2018. All exacerbations and clinical parameters, including treatment details for exacerbations and both remission and re-exacerbation dates, were identified during the observation period. Two different endpoints, the cumulative incidence rates of surgical resection and re-exacerbation, were evaluated separately in moderate to severe exacerbation events. Among 1401 patients, 1626 exacerbation events were determined according to a partial Mayo score (remission: < 2, mild: 2-4, moderate: 5-7, and severe: > 7). During the observation period, as administration rates of biologics increased, both surgical resection and hospitalization rates decreased, for 959 moderate to severe exacerbation events. We confirmed that biologics significantly reduced the cumulative re-exacerbation rate in moderate to severe exacerbation events during the study period compared with suboptimal therapies (a 0.507-fold decreased risk according to COX regression analysis, P < 0.001). However, they had not enough impact in reducing the cumulative incidence rate of surgical resection in moderate to severe exacerbation events that were corticosteroid-refractory or dependent (a 0.878-fold decreased risk according to COX regression analysis, P = 0.606). Biologics may improve remission duration, but these agents had no significant impact in reducing the risk of surgical resection in moderate to severe active UC.

Clinical results following colonic resection for ulcerative colitis in elderly individuals (elderly-onset vs. nonelderly onset)

BACKGROUND

The incidence of ulcerative colitis (UC) is increasing, but there are few reports comparing elderly UC patients undergoing colectomy for elderly-onset UC (EO) and nonelderly-onset UC (NEO). The aim of this study was to analyze the differences between EO and NEO patients who underwent UC-related surgery.

METHODS

We identified 1973 patients with UC who underwent colectomy at Hyogo College of Medicine between January 1, 1984, and December 31, 2018. Only patients aged 65 years old and older who underwent colectomy were enrolled in this study (n = 221, 11.2%), and their clinical records were retrospectively reviewed. Patients were divided into two groups according to their age at disease onset: those with onset at younger than 60 years old (NEO) and at 60 years old or older (EO).

RESULTS

In the 221 UC patients who underwent colectomy at 65 years old or older, there were 155 cases of EO and 66 cases of NEO. The main surgical indication in NEO patients was colitis-associated cancer/dysplasia (32/66, 47%). In contrast, refractory to medical treatment was the leading cause of surgery in EO patients (80/155, 52%). The distributions of surgical indications were different between the two groups (p < 0.01). The preoperative daily dose of steroids was significantly higher in the EO group than in the NEOgroup (0 mg vs. 10 mg, p < 0.01). The rates of immunosuppressant, infliximab (IFX) and adalimumab use did not differ significantly between the groups. Significantly more patients underwent emergency surgery in the EO group than in the NEO group (14% vs. 35%, p < 0.01). The proportions of patients with postoperative morbidity (Clavien-Dindo grade III or higher) were 17.4% (27/155) in the EO group and 13.6% (9/66) in the NEO group. There was no significant difference between the two groups (p = 0.48). The prognosis of the EO patients who underwent UC-related emergency surgery was worse than that of the NEO patients (p < 0.01). In the EO group, 8 (14.8%) of 54 patients died within 30 postoperative days, while there were no deaths in the NEO group.

CONCLUSION

Among elderly UC patients undergoing UC-related surgery, EO patients undergoing emergency surgery had very poor outcomes, and the mortality rate was 14.8%. In such cases, it is important for physicians and surgeons to begin communication at an early stage so that the optimal surgical timeframe is not missed.

Lower effectiveness of intravenous steroid treatment for moderate-to-severe ulcerative colitis in hospitalised patients with older onset: a multicentre cohort study

BACKGROUND

The increasing incidence of older-onset ulcerative colitis (UC), which has a higher risk of surgery, is a global health issue. However, data regarding intravenous steroid treatment, one of the important treatment options to avoid surgery, for older-onset UC is lacking.

AIMS

To evaluate the association between onset age and effectiveness of intravenous steroids in UC.

METHODS

This retrospective multicentre (27 facilities) cohort study included moderate-to-severe hospitalised UC patients who underwent their first intravenous steroids between April 2014 and July 2019. The primary outcome was clinical remission at day 30, using two-item patient-reported outcome scoring. The key secondary outcomes were risks of surgery and adverse events (death, infection and venous thrombosis) within 90 days. A modified Poisson regression model was used for analysis.

RESULTS

Overall, 467 UC patients (384 younger-onset and 83 older-onset) were enrolled. Clinical remission at day 30 was observed in 252 (65.6%) among younger-onset patients and 43 (51.8%) among older-onset patients (adjusted risk difference, -21.7% [95% CI, -36.1% to -7.2%]; adjusted risk ratio [ARR], 0.74 [95% CI, 0.59 to 0.93]). The risks of surgery and adverse events were higher in older-onset UC (20.5% vs. 3.1%; ARR, 8.92 [95% CI, 4.13 to 19.27], 25.3% vs. 9.1%; ARR, 2.19 [95% CI, 1.22 to 3.92], respectively). Four deaths occurred, all involving older-onset UC. The risks of infection and venous thrombosis were also higher in older-onset UC (18.1% vs. 8.6%, 7.2% vs. 0.5%, respectively).

CONCLUSIONS

Older-onset was associated with a lower effectiveness of intravenous steroids with higher risks of surgery and adverse events in UC.

Essential updates 2020/2021: Colorectal diseases (benign)—Current topics in the surgical and medical treatment of benign colorectal diseases

The development of new drugs for inflammatory bowel disease (IBD) is remarkable, and treatment strategies using multiple agents and various techniques are required; however, the treatment strategy is likely to be complex. Therefore, appropriate evaluation of traditional surgical treatment strategies and accurate knowledge of the efficacy and limitations of novel treatments are required. Total infectious complications were found to be associated with the use of corticosteroids and anti‐tumor necrosis factor‐α agents, but not with immunomodulators, anti‐integrin agents, and 5‐aminosalicylic acid. Regarding surgical procedures for IBD, conceived anastomosis methods, including Kono‐S for Crohn's disease stenosis, are associated with better outcomes than conventional techniques. Autologous cell transplantation for Crohn's fistulae has been shown to have a favorable outcome. Diverticulitis is increasing and will be treated more frequently in the future. Risk factors for the incidence of diverticulitis and differences in pathogenesis according to right or left side diverticulitis have been reported. Antibiotic therapy may be omitted for uncomplicated diverticulitis. Moreover, regarding surgical procedures, both bowel resection and anastomosis are associated with favorable short‐term outcomes, higher stoma closure rate, and superior medical economy compared to Hartmann's procedure. Risk factors for recurrence after diverticulitis surgery may provide better postoperative follow‐up. In this review, we explore the current topics of colorectal benign diseases, focusing on IBD and diverticulitis, based on clinical trials and meta‐analyses from 2020‐2021. This review consolidates the available knowledge and improves the quality of surgical procedures and perioperative management for IBD and diverticulitis.

Inflammatory Bowel Disease and Sarcopenia: Its Mechanism and Clinical Importance

Malnutrition is a major contributor to muscle loss and muscle dysfunction, known as sarcopenia. Malnutrition is common in patients with inflammatory bowel disease (IBD). IBD includes ulcerative colitis (UC) and Crohn’s disease (CD). The number of patients with IBD has recently been increasing. More severe malnutrition is often seen in CD compared to UC, probably due to CD affecting the main site of nutrient absorption, extensive mucosal lesions, fistulas, short bowel syndrome after resection, or obstruction of the gastrointestinal tract. A recent meta-analysis showed the high prevalence of sarcopenia in patients with IBD, and thus sarcopenia is a very important problem for IBD. Although IBD is more common in younger patients, sarcopenia can develop through a variety of mechanisms, including malnutrition, chronic inflammation, increased inflammatory status in adipose tissue, vitamin deficiency, and imbalance of the muscle–gut axis. In addition, sarcopenia has a negative impact on postoperative complications and hospital stay in patients with IBD. Appropriate intervention for sarcopenia may be important, in addition to clinical remission and endoscopic mucosal healing in patients with IBD. Much more attention will thus be paid to sarcopenia in patients with IBD. In this review, we outline IBD and sarcopenia, based on the current evidence.

Clinical Course of Ulcerative Colitis Associated with an Age at Diagnosis: A Recent Japanese Database Survey

The onset age of ulcerative colitis has been increasing in several countries. Furthermore, the number of elderly patients with ulcerative colitis has been increasing in an aging society. We investigated the incidence of ulcerative colitis patients in Japan using a large-scale health insurance claims database to survey the ulcerative colitis incidence ratio and the clinical characteristics in late-onset ulcerative colitis patients. Newly diagnosed 2,791 ulcerative colitis between 2015 and 2018 was investigated. Medical treatment within 12 months of diagnosis was analyzed among 0-19, 20-39, 40-59 and 60-75 age groups. The mean age at diagnosis was 40.3 years (SD: 12.9), and the incidence ratio peaked in the 40's. Most of patients received 5-aminocylitic acid (91.7%), a subset of patients received prednisolone (20.1%), and a small number of patients took immunomodulator (6.8%), cytapheresis (3.3%), anti-TNFα therapy (4.3%), and colectomy (1.0%) within 12 months after diagnosis. All treatments except colectomy were most frequent in the 0-19 age group; however, colectomy was most frequent in 60-75 age group. The clinical course of ulcerative colitis that developed in adults did not differ significantly in terms of medical treatment within 12 months from the onset; meanwhile, the surgery rate was high in elderly patients. It is necessary to pay close attention to future trends regarding the aging of the onset age and the treatment, especially for late-onset ulcerative colitis patients.

Real-world data for golimumab treatment in patients with ulcerative colitis in Japan: interim analysis in post-marketing surveillance

Background/Aims

Golimumab (GLM) is an anti-tumor necrosis factor-α drug approved for treating moderate-to-severe active ulcerative colitis (UC). A 52-week post-marketing surveillance (PMS) was initiated to evaluate its safety and effectiveness in patients with UC in Japan. We present an interim report of the ongoing PMS.

Methods

Patients received 200 mg of subcutaneous GLM at week 0, 100 mg at week 2, and 100 mg 4 weekly thereafter. The safety analysis set included 392 patients with UC, and the effectiveness analysis set 387 patients. Safety and effectiveness were assessed at week 6.

Results

Adverse drug reactions (ADRs) were reported in 8.2% (32/392) and serious ADRs in 4.6% (18/392). The most frequent ADRs were infection and infestation (3.3%), with herpes zoster being the most common. ADRs were significantly higher in patients with concomitant corticosteroid use (odds ratio [OR], 3.45; 95% confidence interval [CI], 1.40–9.68). No significant difference in ADR incidence was observed between patients aged ≥65 and <65 years (OR, 1.23; 95% CI, 0.35–3.47). Six-week effectiveness of GLM was confirmed by a decrease in the partial Mayo score (–2.3; 95% CI, –2.6 to –2.1) and C-reactive protein levels (–0.64; 95% CI, –0.92 to –0.36), including in the biologics-experienced population.

Conclusions

The safety and effectiveness of GLM at week 6 in a real-world setting were demonstrated in patients with UC in Japan. ADR patterns were consistent with previous reports with no new safety signals. Concomitant corticosteroid use may be associated with increased ADR incidence. The final results of the ongoing PMS are necessary for further evaluation.

Clinical characteristics of ulcerative colitis in elderly patients

The incidence of ulcerative colitis (UC) in elderly patients is increasing. Elderly UC patients are likely to exhibit distinct features both at diagnosis and during follow-up. Age-related problems, including complications, immune dysfunction, and multidrug use, make the diagnosis and treatment of elderly UC more challenging. Suboptimal treatment considering adverse events leads to poor clinical outcome in elderly UC patients. Here, we reviewed the epidemiology, clinical presentation, medical therapy, colorectal cancer surveillance of UC in elderly patients.

The clinical practice of ulcerative colitis in elderly patients: An investigation using a nationwide database in Japan

Background and Aim

The number of elderly patients with ulcerative colitis (UC) is increasing worldwide. The clinical practice of associated treatment is still unclear. Therefore, we aimed to analyze clinical treatment realities and mortality in elderly and non‐elderly patients with UC.

Methods

We collected UC patients' data using the diagnosis procedure combination (DPC) database system and divided eligible patients into elderly (≥65 years) and non‐elderly (≤64 years) groups. We investigated and compared their therapeutic histories (medical treatments vs. surgery). Logistic regression analysis was conducted to identify clinical factors affecting surgery and in‐hospital death in each group.

Results

The rates of systemic steroid injection, molecular targeting drug usage, and surgery were not different between the two age groups. Meanwhile, the rate of in‐hospital death in elderly patients was higher than that in non‐elderly patients (2.7% vs. 0.19%, P < 0.0001). Multivariate analysis revealed that lower body mass index, treatment at an academic hospital, smoking history, molecular targeting drug use, and treatment with systemic steroid injection affected the rate of surgery in the elderly group. Multivariate analysis also revealed that male and older age affected the rate of in‐hospital death in the elderly group. Similar tendencies were also recognized in the non‐elderly group.

Conclusions

The clinical practice of treating elderly patients with UC is overall not different from treating non‐elderly patients with UC. Although the form of medical treatment and surgery rate for elderly patients with UC may not be significantly different from non‐elderly patients, the rate of in‐hospital death for elderly patients is higher.

Epidemiology and Natural History of Elderly-onset Inflammatory Bowel Disease: Results From a Territory-wide Hong Kong IBD Registry

BACKGROUND

Elderly-onset inflammatory bowel disease [IBD], defined as age ≥60 at diagnosis, is increasing worldwide. We aimed to compare clinical characteristics and natural history of elderly-onset IBD patients with those of adult-onset IBD patients.

METHODS

Patients with a confirmed diagnosis of IBD from 1981 to 2016 were identified from a territory-wide Hong Kong IBD registry involving 13 hospitals. Demographics, comorbidities, clinical features, and outcomes of elderly-onset IBD patients were compared with those of adult-onset IBD patients.

RESULTS

A total of 2413 patients were identified, of whom 270 [11.2%] had elderly-onset IBD. Median follow-up duration was 111 months (interquartile range [IQR]: 68-165 months). Ratio of ulcerative colitis [UC]: Crohn's disease [CD] was higher in elderly-onset IBD than in adult-onset IBD patients [3.82:1 vs 1.39:1; p <0.001]. Elderly-onset CD had less perianal involvement [5.4% vs 25.4%; p <0.001] than adult-onset CD. Elderly-onset IBD patients had significantly lower cumulative use of immunomodulators [p = 0.001] and biologics [p = 0.04]. Elderly-onset IBD was associated with higher risks of: cytomegalovirus colitis (odds ratio [OR]: 3.07; 95% confidence interval [CI] 1.92-4.89; p <0.001); herpes zoster [OR: 2.42; 95% CI 1.22-4.80; p = 0.12]; and all cancer development [hazard ratio: 2.97; 95% CI 1.84-4.79; p <0.001]. They also had increased number of overall hospitalisations [OR: 1.14; 95% CI 1.09-1.20; p <0.001], infections-related hospitalisation [OR: 1.87; 95% CI 1.47-2.38; p <0.001], and IBD-related hospitalisation [OR: 1.09; 95% CI 1.04- 1.15; p = 0.001] compared with adult-onset IBD patients.

CONCLUSIONS

Elderly-onset IBD was associated with increased risk of infections and cancer development, and increased infection- and IBD-related hospitalisations. Specific therapeutic strategies to target this special population are needed.

Approach to the Seamless Management of Inflammatory Bowel Disease, Considering Special Situations, Shared Decision-Making, and Disease Burden

BACKGROUND

While the number of inflammatory bowel disease (IBD) patients has been steadily increasing, a lot of effective treatments have become available, including biological drugs. However, there still exists no effective treatment universally for all types of IBD patients. We have continuously discussed "Total Care" for IBD patients in the 3 consecutive annual meetings of the Japanese Gastroenterological Association from the 14th meeting to the 16th meeting in 2018-2020.

SUMMARY

In the 14th meeting, we summarized cross-sectional issues under the title "From Total Care to Microbiota" as for their subthemes. In the 15th meeting, under the title of "Consensus and Pitfalls in Special Situations," we discussed the thiopurine treatment for the patients in their childhood or pregnancy and lactation period as well as the cytapheresis treatment for elderly patients. In the 16th meeting, under the title "Future Issues in Special Situations: Including Disease Burden," we discussed about the issues in childhood-onset IBD, including transitional care and the new option of combination of treatments in their adulthood and their disease burdens. Key Messages: "Total Care" for IBD patients should be considered from a broad perspective with shared decision-making. It is imperative to involve medical staff members for careful handling of a wide range of disease burdens.

Real-World Long-Term Remission Maintenance for 10 Years With Thiopurines in Ulcerative Colitis

BACKGROUND

To evaluate the therapeutic outcomes and long-term prognosis of patients receiving remission maintenance therapy using thiopurines for ulcerative colitis (UC).

METHODS

Of 193 biologic-naive patients with UC who began thiopurine therapy at our hospital between 2000 and 2019, 161 patients were included after the exclusion of 32 patients who were intolerant to thiopurines and discontinued the drugs within 3 months. Short- and long-term clinical outcomes were retrospectively analyzed. Subsequently, the patients were divided into 2 groups (exacerbation and nonexacerbation groups) and clinical outcomes were analyzed and compared. Multivariate analysis was performed to identify risk factors for UC exacerbation. Finally, adverse events observed in 193 patients were examined.

RESULTS

Clinical remission rates at 2 months, 6 months, and 1 year after the start of thiopurine therapy were 50.0%, 58.0%, and 63.9%, respectively. At 1, 2, 5, and 10 years, the cumulative event-free rates were 77.6%, 60.8%, 48.5%, and 42.2%, respectively; the cumulative UC exacerbation rates were 17.0%, 32.5%, 42.2%, and 43.7%, respectively; and the cumulative colectomy rates were 0.6%, 1.3%, 8.5%, and 10.7%, respectively. Prior use of steroids (dose ≥40 mg/d) was a significant risk factor for UC exacerbation during remission maintenance therapy with thiopurines (hazard ratio, 2.26; 95% confidence interval, 1.18-4.34; P = 0.014). Adverse reactions occurred in 42 patients (21.8%; 46 events). Concurrent diseases were observed in 18 patients (9.3%).

CONCLUSIONS

Thiopurines were effective for long-term maintenance of remission in steroid-dependent/refractory UC. Their effect weakened in only a few patients continuously treated with them for 4 years or longer.

Relation of geriatric nutritional risk index with clinical risks in elderly-onset ulcerative colitis

BACKGROUND AND AIM

Worldwide increasing aging societies have many elderlies with intractable diseases including ulcerative colitis (UC). Reportedly, each patients' frailty as well as chronological age is a clinical risk factor of elderly-onset UC (EOUC). Because malnutrition is one of the major manifestations of frailty, we aimed to investigate the effect of malnutrition on the prognosis of EOUC with geriatric nutritional risk index (GNRI), a prognostic tool for several diseases in the elderly to estimate malnutrition, and to evaluate clinical risks among EOUC patients in Japan, the world-leading aging society.

METHODS

The EOUC patients (≥ 65 years at diagnosis, n = 2778) in the previous nationwide survey were classified by age and GNRI, and odds ratios (ORs) of hospitalization and UC-related surgery were determined to evaluate the effects of malnutrition on the EOUC patients as well as aging.

RESULTS

The risks of hospitalization and surgery were elevated as age advanced. The value of GNRI, negatively correlated with disease activity (r = -0.53), could distinguish severe activity (cutoff ≤ 86.82, sensitivity = 0.79, and specificity = 0.77) and discriminate the EOUC patients suffering from surgery and hospitalization. In a multivariate analysis, GNRI ≤ 86.82 was a higher risk of hospitalization (OR: 4.0, 95% CI, 2.5-6.5) and surgery (OR: 2.7, 95% CI, 0.98-7.4) than cutoff age ≥ 75 years old (OR of hospitalization and surgery were 1.4 [95% CI, 0.99-2.0] and 2.3 [95% CI, 0.8-6.3], respectively).

CONCLUSION

Malnutrition estimated by GNRI was significantly related with poor clinical courses of the EOUC patients, suggesting that evaluation of nutritional status at the onset might be useful for predicting risks of clinical courses.

Ketorolac after colectomy for ulcerative colitis in children: An analysis of opioid utilization and postoperative complications

INTRODUCTION

Enhanced recovery protocols include multimodal perioperative pain control and frequently include use of NSAIDs. There is conflicting evidence that ketorolac use in inflammatory bowel disease (IBD) may precipitate disease flares and postoperative complications. The outcomes of children who receive ketorolac in this setting are not well known. We sought to evaluate ketorolac utilization in children following colectomy for ulcerative colitis.

METHODS

All patients undergoing colectomy for ulcerative colitis between 2007 and 2017 at a tertiary children's hospital were reviewed. We collected patient age, duration of symptoms, operative details, medication utilization, length of stay, and postoperative complications. We performed a cohort comparison of these variables across patients who did vs. did not receive postoperative ketorolac.

RESULTS

Sixty children were identified with median age at diagnosis of 12.6 years (IQR: 9.9-14.5). At colectomy, patients had a median PUCAI score of 60 (45-70), ESR 34 mm/h (15-50), hemoglobin 10.9 g/dL (9.3-12.9), and albumin 3.1 g/dL (2.4-3.8). Postoperatively, 45% (n = 27) received ketorolac. Patients in both cohorts had a similar length of stay, duration of opioid exposure, total morphine equivalents utilized, readmission rate, and unexpected return to the operating room. There were no documented cases of postoperative bleeding, acute kidney injury, or disease related flares among children receiving ketorolac.

CONCLUSIONS

Administration of ketorolac after colectomy in IBD was not associated with an increase in any postoperative complications, though the study was underpowered to detect these differences. However, ketorolac administration did not lead to a decreased utilization of opioid analgesia. Further prospective research is necessary to understand whether ketorolac in this population is safe and offers benefit.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

III.

Variation in care of patients with elderly-onset inflammatory bowel disease in Ontario, Canada: A population-based cohort study

Background

Variation in health care, when not based on patient preference, may result in poorer care. We determined whether variation in health services utilization, gastroenterologist care and outcomes existed among patients with elderly-onset inflammatory bowel disease (IBD).

Methods

Patients with IBD (diagnosed ≥65 years) were identified from population-based health administrative data from Ontario, Canada (1999 to 2014). We assessed variation across multispecialty physician networks in gastroenterologist care and outcomes using multilevel logistic regression. Median odds ratios (MOR) described variation. We evaluated the association between gastroenterologist supply, specialist care and outcomes.

Results

In 4806 patients, there was significant variation in having ever seen a gastroenterologist (MOR 3.35, P < 0.0001), having a gastroenterologist as the primary IBD care provider (MOR 4.16, P < 0.0001), 5-year colectomy risk in ulcerative colitis (MOR 1.38, P = 0.01), immunomodulator use (MOR 1.47, P = 0.001), and corticosteroid use (MOR 1.26, P = 0.006). No variation in emergency department visits, hospitalizations or intestinal resection (Crohn’s) was noted. Patients in networks with fewer gastroenterologists were less likely to see a gastroenterologist (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.56), have a gastroenterologist as their primary care provider (OR 0.27, 95% CI 0.12 to 0.59), be hospitalized within 5 years (OR 0.82, 95% CI 0.69 to 0.98), and be prescribed biologics within 1 year (OR 0.50, 95% CI 0.28 to 0.89).

Conclusions

Utilization of gastroenterology care in patients with elderly-onset IBD varies greatly. Patients treated by gastroenterologists and in networks with more gastroenterologists have better outcomes. There is a need to ensure all individuals with IBD have equal access to and utilization of specialist care to ensure the best possible outcomes.

Management of elderly ulcerative colitis in Japan

Japan has the largest aging society, where many elderly people have intractable diseases including ulcerative colitis (UC). Along with the increasing total number of UC patients, the number of elderly UC patients has also been increasing and will continue to do so in the future. Although the clinical features and natural history of UC in the elderly have many similarities with UC in the non-elderly population, age-specific concerns including comorbidities, immunological dysfunction, and polypharmacy make the diagnosis and management of elderly UC challenging compared to UC in non-elderly patients. Based on increasing data related to elderly UC patients from Japan, as well as other countries, we reviewed the epidemiology, clinical course, differential diagnosis, management of comorbidities, surveillance, medical therapy, and surgery of UC in the elderly.