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Remission rates of older Adults With Late-Onset UC vs. Younger Patients

Older Adults With Late-Onset Ulcerative Colitis More Likely to Experience Steroid-Free Remission at 1 Year Than Younger Patients

Clin Gastroenterol Hepatol. Published online April 5, 2010.

Adults diagnosed with ulcerative colitis (UC) at age 50 years or older had a higher incidence of former tobacco use but were more likely than patients with UC between the ages of 18 and 30 years to be in steroid-free remission at 1 year after diagnosis, according to a retrospective study published online April 5 in Clinical Gastroenterology and Hepatology.

"Epidemiologic studies of [UC] reveal a bimodal distribution of disease onset with an initial peak in the third decade and a smaller second peak between the ages of 50 and 80," explain lead author Christina Y. Ha, MD, from the Division of Gastroenterology, Mount Sinai School of Medicine, New York City, and colleagues. Despite an aging population and, therefore, a rise in incidence of late-onset UC, little is understood about "the influence of age on the presentation, clinical course, and therapeutic response of patients with [early vs late] adult-onset [UC]."

Because risk factors for UC and immune function vary depending on age, the authors "sought to determine if disease behavior or clinical outcomes differed between patients diagnosed with UC in later vs earlier stages of adulthood."

Using a retrospective cohort design, 295 patients treated at an inflammatory bowel disease (IBD) clinic at Washington University in St. Louis between 2001 and 2008 were analyzed for

* IBD-related medication use;
* disease extent and severity at the time of diagnosis, evaluated by the Montreal classification system and the modified Truelove and Witts Severity Index;
* hospitalizations for colitis flares;
* elective and emergent colectomies;
* mortality rate within the first year of diagnosis; and
* primary clinical endpoint of steroid-free remission 1 year after disease onset.

The 2 groups compared were defined as early onset, diagnosed between the ages of 18 and 30 years (n = 155), and late onset, newly diagnosed at age 50 years or older (n = 140). Additional demographic data gathered and differences assessed included sex, smoking history, and family history of UC.

More patients with late-onset UC achieved steroid-free clinical remission compared with younger patients (64% vs 49%; P = .01) at 1 year. There were no sex differences in rates of remission between the 2 groups. There was a trend toward greater numbers of colectomies for those with early-onset UC; however, the difference was not statistically significant, nor were differences in hospitalization rates (n = 57 vs n = 66; P = .09) until a subset of the older group was considered. Specifically, those with UC onset at age 60 years or older were more likely to be hospitalized for colitis flares compared with patients with early-onset UC (P = .03).

In terms of overall medication use during the first year of disease, there were no statistical differences between the 2 groups, with slightly higher rates of 5-aminosalicylate (5-ASA) use in the patients with late-onset UC, similar rates of immunomodulator and infliximab use, and most patients needing oral or intravenous steroids within the first year of disease (63.4% of early-onset and nearly 68% of late-onset patients). Of those prescribed immunomodulators (but not infliximab or 5-ASA), a greater number of late- vs early-onset patients achieved steroid-free remission at 1 year (43.9% vs 17.5%, respectively; P = .016). Of those who required steroids at the time of diagnosis, a higher percentage of late- vs early-onset UC adults were able to wean off of the steroids and remain steroid free at 1 year (P = .019).

As the authors note, early-onset UC appears to have a genetic component, whereas late-onset UC is more attributable to age-related changes in the immune system and intestinal barrier function, as well as other environmental influences such as former smoking history. The study results support each of these assertions and lend credence to earlier trials with similar outcomes. Nearly 52% of the late-onset group were former smokers compared with 13.5% of ex-smokers in the younger patients (P < .001). More than 21% of patients aged 30 years and younger had a family history of IBD compared with 10.8% in the older group (P = .008).

Strengths of this trial include use of a large, well-defined study population and direct comparison of patients with late- vs early-onset UC. Limitations include the retrospective design; use of a tertiary-care center, in which patients may be sicker; variability of treatment decisions by physicians at the center; reliance on medical records for accuracy and descriptions of colonoscopy findings; and lack of endoscopic criteria to corroborate clinical remission at 1 year.

"The number of patients diagnosed with late-onset UC will likely continue to increase with the aging of the population," the investigators write. "Treatment of the older UC patient is often challenged by concomitant medication use and comorbid conditions.... Given that older patients are at increased risk for steroid related complications, [our] work underscores the importance of early initiation of maintenance therapy with 5-ASA and consideration of immunomodulator therapy."

The authors go on to call for "additional research focusing on the therapeutic response to these medications in the late-onset UC population," as well as "further investigation into the environmental and genetic factors that differentiate late- versus early-onset UC."