What is the recommended treatment plan for a patient in their late 80s with pancolitis (ulcerative colitis involving the entire colon)?

Treatment of Pancolitis in Patients in Their Late 80s or Older

For patients in their late 80s with pancolitis (ulcerative colitis involving the entire colon), prioritize gut-selective biologics—specifically vedolizumab or ustekinumab—over anti-TNF agents when moderate-to-severe disease requires biologic therapy, while simultaneously addressing frailty, comorbidities, and infection risk through comprehensive geriatric assessment. 1

Initial Assessment and Risk Stratification

Before initiating therapy, perform the following evaluations specific to elderly patients:

• Assess frailty status, comorbidities, polypharmacy, bone density, cognitive function, and depression, as these factors significantly impact treatment decisions and outcomes in elderly inflammatory bowel disease patients 1, 2
• Measure fecal calprotectin and C-reactive protein to objectively quantify disease activity, recognizing that CRP may remain normal despite active inflammation 1, 2
• Screen for latent tuberculosis and hepatitis B infection before starting any immunosuppressive therapy 1
• Evaluate renal and hepatic function to guide medication dosing and identify contraindications 1

Medical Therapy Algorithm

Mild to Moderate Disease

• Start with aminosalicylates (mesalamine) as first-line therapy due to lack of systemic immunosuppression 1, 3, 4
• Mesalamine is appropriate for both induction and maintenance of remission in mild-to-moderate ulcerative colitis 5, 6
• Monitor for rare interstitial nephritis, which is particularly concerning in elderly patients with baseline renal impairment 1

Moderate to Severe Disease Requiring Corticosteroids

• Use budesonide-MMX over systemic corticosteroids for left-sided ulcerative colitis when possible, as budesonide has lower systemic bioavailability and reduced risk of adrenal suppression 1
• If systemic corticosteroids are necessary, do not use them for maintenance therapy as they are ineffective for sustaining remission and carry significant toxicity in elderly patients 1, 6
• Taper corticosteroids according to the time required to induce remission and immediately initiate corticosteroid-sparing therapy 1, 7
• Implement bone health measures given the 40% higher fracture risk in inflammatory bowel disease patients, compounded by age and corticosteroid use 2

Advanced Therapy Selection for Moderate to Severe Disease

When biologic therapy is required, the treatment hierarchy for patients in their late 80s is:

1. Vedolizumab (first choice) – gut-selective α4β7 integrin inhibitor, maybe slightly favored in those with higher risk of complications 1, 4
2. Ustekinumab (second choice) – IL-12/IL-23 inhibitor, maybe slightly favored in those with higher risk of complications 1, 4
3. Anti-TNF agents (infliximab, adalimumab) – consider only after assessing ability to administer and adhere to prescribed regimen 1, 8
4. Tofacitinib – JAK inhibitor with higher risk of venous thromboembolism with 10 mg twice daily in those with cardiac risk factors; use 5 mg twice daily for maintenance if selected 1, 4

The rationale for prioritizing vedolizumab and ustekinumab over anti-TNF agents in elderly patients is their gut-selective mechanism and potentially lower systemic immunosuppression, reducing infection risk. 1

Maintenance Therapy

• Continue the biologic agent that successfully induced remission at standard maintenance dosing 1
• Thiopurines (azathioprine, 6-mercaptopurine) should be used only in select cases due to higher risk of lymphoma and non-melanoma skin cancer when compared to more targeted biologics, with absolute risk increasing significantly with age 1, 2
• Avoid prolonged corticosteroid use for maintenance; transition to steroid-sparing agents 1, 6

Infection Prevention and Monitoring

• Screen for and vaccinate against preventable infections (influenza, pneumococcal, herpes zoster) ideally before starting immunosuppression, as elderly inflammatory bowel disease patients face increased risk of serious infections including pneumonia and opportunistic infections 2
• Monitor for non-melanoma skin cancers and lymphoma, particularly if using thiopurines 2
• Assess for Clostridioides difficile infection in any elderly patient with worsening diarrhea or colitis symptoms, as infection markedly raises morbidity and mortality 9

Multidisciplinary Care Coordination

Engage a multidisciplinary team including:

• Gastroenterologist for disease management 2
• Primary care provider or geriatrician for comorbidity management 2
• Pharmacist for medication reconciliation and polypharmacy reduction 2
• Nutritionist for nutritional support 2
• Mental health professional for depression and cognitive assessment 2
• Advanced inflammatory bowel disease nurse for care coordination, education, and monitoring 2

Critical Pitfalls to Avoid

• Do not delay or prolong corticosteroid therapy out of concerns for immune therapy–associated risks; the risks of uncontrolled inflammation and prolonged steroid exposure outweigh the risks of appropriately selected biologic therapy 1
• Do not abruptly discontinue essential cardiac medications without cardiology consultation, as abrupt withdrawal can impair colonic perfusion and worsen outcomes 9
• Do not use NSAIDs, as they may precipitate or worsen ischemic changes in the colon and increase gastrointestinal bleeding risk 9, 10
• Do not assume that conservative management will succeed in all cases; early surgical consultation is required for severe presentations with peritonitis, clinical deterioration, or failure of medical therapy 1, 9
• Do not use tofacitinib 10 mg twice daily in elderly patients with cardiac risk factors due to increased venous thromboembolism risk; use 5 mg twice daily for maintenance 1

Surgical Considerations

• Surgical decision-making should incorporate disease severity, impact on functional status and independence, candidacy for surgery based on comorbidities, and risk of postoperative complications, which is higher in elderly patients 2
• Within 5 years of diagnosis, approximately 20% of patients with ulcerative colitis are hospitalized and approximately 7% undergo colectomy 4
• Early involvement of a colorectal surgeon is advised for patients with severe presentations to facilitate rapid operative intervention if needed 9

Monitoring and Follow-Up

• Measure fecal calprotectin and C-reactive protein regularly to objectively assess disease activity and guide treatment adjustments 1, 2
• Colonoscopy surveillance at 8 years from diagnosis for dysplasia monitoring, as people with ulcerative colitis have a 1.7-fold higher risk for colorectal cancer compared with the general population 4
• Monitor renal function, blood pressure, and signs of infection at each visit when on biologic therapy 1, 10