2093 Uncharted Territory: Biologic Therapies for Elderly Patients With Refractory Ulcerative Colitis

Abstract

INTRODUCTION: Ulcerative colitis (UC) is becoming more common among people older than 65. However, diagnosis in these patients is challenging due to the presence of comorbidities that can resemble UC and symptoms being more subtle. UC treatment guidelines are based on trials of short duration that often exclude elderly patients. Therefore, when treating this population, choice of therapy should be tailored for each patient individually. The use of biologic agents in this population is controversial given the lack of strong evidence-based trials; with most data coming from the rheumatology literature. It can also be difficult as benefits are masked by multiple comorbidities and long term progression of the disease. We present a case series of two patients with refractory UC who had good outcomes with biologic therapy. CASE DESCRIPTION/METHODS: Case 1: 87-year-old male with left sided UC and history of prostate cancer treated with brachytherapy in 2013, complicated by radiation proctitis. He was initially maintained on 5-ASA, but had numerous hospitalizations with persistent diarrhea, rectal bleeding, dehydration, and C. difficile colitis over the course of 1 year. Sigmoidoscopy revealed severe “Mayo 3” colitis (Figures 1 and 2). He became steroid dependent, so was then started on adalimumab with improvement of his Disease Activity Index and no further UC related hospitalizations. Case 2: 80-year-old female with severe UC pancolitis diagnosed in 2017 and comorbidities of HTN, NIDMM, HLD, asthma, GERD, and stroke. She was initially on mesalamine enemas, which she did not tolerate due to a salicylate allergy. She was then switched to hydrocortisone enemas, then switched to adalimumab, with resultant persistent recurrence of flares. She is now on infliximab and in remission since 2018. DISCUSSION: The efficacy of biologic agents in the elderly UC patients, as compared to younger patients, has not been studied extensively. However, our experience has shown good outcomes in this population. Possible adverse effects of anti-TNF therapy include higher rates of cardiovascular diseases (e.g, heart failure), malignancy, psoriasis, and opportunistic infections. Advantages of this therapy are low rates of drug interactions and lesser impact on comorbidities when compared with usual treatments like steroids or 6-MP. Our experience supports the use of biologics in elderly patients with refractory UC.