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P631. Natural history of elderly onset inflammatory bowel disease – Sydney IBD Cohort (1942–2012)

V. Kariyawasam1, P. Lunney2, T. Huang2, K. Middleton2, R. Wang2, C. Selinger2, P. Katelaris2, J. Andrews3, R. Leong2, 1Guy's and St Thomas' NHS Foundation Trust, Gastroenterology, Londond, United Kingdom, 2Concord Repatriation General Hospital, Gastroenterology, Concord, Australia, 3Royal Adelaide Hospital, Dept of Gastroenterology & Hepatology, Adelaide, Australia

Background

The incidence of inflammatory bowel disease (IBD) is increasing in the elderly. They have unique management related issues and hence require individualised therapy. However, little data is available on the natural history of disease and the impact of immunomodulation (IM) (Azathioprine, Mercaptopurine and Methotrexate) to guide such decisions.

Methods

The aim of this study was to describe differences in disease characteristics and treatment modalities in an elderly onset IBD cohort in comparison to a younger onset (YO) IBD cohort. “Sydney IBD cohort” database was interrogated. Patents diagnosed >60 and 16–40 were selected. Patient demographics, disease characteristics as per Montreal classification, medication and surgical history were reviewed.

Results

A total of 284 (12%) had IBD diagnosed >60 with 119 (42%) having Crohn's disease (CD), 144 (51%) ulcerative colitis (UC) and 21 (7%) IBD-unclassified.

Elderly CD patients had a median follow-up (FU) of 7 years (IQR 2–13) and 1012 patient years of FU. The median age of diagnosis was 68 years. The cumulative probability (CP) of commencing IM, having intestinal resection and progression of disease behaviour was significantly lower compared to YO patients. B1 as opposed to B2/B3 was the only significant predictor of decreased need of surgery (P = 0.003) (Table 1).

Elderly UC patients had a median FU of 8 years (IQR 3–15) and 1,374 patient years of FU. The median age of diagnosis was 67 years. They had significantly lower CP of being initiated on IM as opposed to YO but with no difference in the CP of colectomy over time. Early introduction of IM predicted decreased CP of having surgical resection (P = 0.014) in elderly (Table 2).

Table 1. Comparison between elderly and younger onset Crohn's disease patients (expressed as percentages)
 EOYOp
L1/L2/L315/62/2324/31/45<0.0001
B1/B2/B374/18/871/18/110.571
Perianal14200.123
Long-term steroid use (LTS)56640.113
CP of progression of disease behaviour at 1/5/10 years1/4/67/15/210.011
CP of intestinal resection at 1/5/10 years13/17/2718/31/430.001
CP of introduction of IM at 1/5/10 years16/22/2331/48/60<0.0001
Table 2. Comparison between elderly and younger onset ulcerative colitis patients (Expressed as percentages)
EOYOp
E1/E2/E323/52/2537/40/230.026
LTS43460.607
CP of intestinal resection at 1/5/10 years4/7/122/4/70.20
CP of introduction of IM at 1/5/10 years2/9/99/17/240.001

Conclusion

CD diagnosed in elderly is less likely to progress and require surgery despite significantly lower exposure to IM. UC patients' have similar colectomy rates as YO despite having lower use of IM. Careful patient selection is required prior to initiating IM in this group of patents, as risk/benefit of long-term immunosuppression may not be as acceptable as in YO patients.