Elderly patients and inflammatory bowel disease

Table 1 Phenotypic characteristics of inflammatory bowel disease in elderly-onset inflammatory bowel disease

	Crohn’s disease	Ulcerative colitis
Location	Colonic or ileo-colonic	Left sided or extensive disease more common than isolated proctitis
Symptoms	Less bleeding and abdominal pain than younger patients	Less diarrhoea, abdominal pain and weight loss than younger patients
Disease behaviour	Inflammatory; less progression to penetrating and structuring disease	More likely to remain stable
First episode	More severe than in younger patients	More severe than in younger patients
Extra-intestinal manifestations	Less common than in younger patients	Less common than in younger patients
Family history	Less common	Less common
Cancer risk	Higher risk of non-Hodgkin lymphoma with thiopurines and of non-melanoma skin cancer with anti-TNF therapy	Higher risk of non-Hodgkin lymphoma with thiopurines and of non-melanoma skin cancer with anti-TNF therapy

Table 2 Differential diagnosis of inflammatory bowel disease

Disease	Clinical characteristics	Additional features
Segmental colitis associated with diverticulosis	Diarrhoea with bleeding	Segmental peridiverticular distribution
	Abdominal pain	Rectum and proximal colon spared
Radiation colitis	Diarrhoea with bleeding and abdominal pain/cramps	Telangiectasia and fibrosis seen at histology
	Proctitis (urgency and tenesmus)
	Symptoms often weeks to years after abdominal or pelvic radiation
NSAID-induced colitis	Diarrhoea with recurrent abdominal pain	Lesions isolated
	Obstruction or perforation	Any part of intestine may be affected
	Iron deficiency anaemia	Diaphragm like small bowel strictures
		Exacerbate existing CD or UC
Ischaemic colitis	Sudden onset of abdominal pain	Segmental distribution of colitis
	Diarrhoea with bleeding	Typically sigmoid/left sided colitis
		Rectum spared and abrupt cut off with non-involved segment
Infective colitis	Diarrhoea with bleeding	Possible pseudomembranes with Clostridium difficile colitis
	Constitutional symptoms such as fever	Stool cultures usually diagnostic
		Rapid resolution with appropriate antibiotic therapy
Solitary rectal ulcer	Bleeding per rectum with straining	Mucosal thickening
		Crypt architectural distortion
		Collagen deposition and smooth muscle in lamina propria

NSAID: Nonsteroidal anti-inflammatory drug; CD: Crohn’s disease; UC: Ulcerative colitis.

Table 3 Drug interactions of medications used in the treatment of inflammatory bowel disease relevant to elderly patients

IBD drug	Drug interaction
Aminosalicylates	Increase levels of thiopurine metabolite 6-TGN through weak TPMT inhibition
	Interact with warfarin and increase INR (particularly Olsalazine)
Metronidazole	Increases levels of: Simvastatin; Calcium channel blockers; sildenafil and lithium
	Antabuse (disulfuram) like reaction with ethanol
	Increased metabolism and consequent clearance when co-administered with phenytoin and phenobarbitone
	Potentiates Warfarin: May increase INR
Ciprofloxacin	NSAIDs: Risk of seizures may be increased
	Theophylline: Levels may increase
	Potentiates Warfarin: May increase INR
	Phenytoin: Levels of phenytoin may decrease
Corticosteroids	Antidiabetic agents: Hypoglycaemic effects may be decreased
	Calcium channel blockers: May increase corticosteroid levels
	Diuretics: Hypokalaemic effects increased
	Warfarin: May increase anticoagulant effects
Thiopurines	Allopurinol: Can lead to bone marrow toxicity
	Aminosalicylates: May lead to increased toxicity and cause leukopenia/myelosuppression
	Clotrimazole, angiotensin–converting enzyme inhibitors: increased risk of leucopenia
	Warfarin: Anticoagulant effect may decrease
Methotrexate	Loop diuretics: Can alter methotrexate concentrations and vice versa
	NSAIDs: Bone marrow suppression and gastrointestinal toxicity
	Penicillins: Increase methotrexate concentration
	Tetracyclines: Increase methotrexate toxicity
	Theophylline levels may be increased
Cyclosporine	Ciprofloxacin, gentamicin and vancomycin: Potentiate renal dysfunction
	Anti-inflammatory drugs and histamine-2 blockers: Potentiate renal dysfunction
	Azithromycin, clarithromycin: Increase cyclosporine levels
	Allopurinol: Increases cyclosporine levels
	Rifampicin: Decreases cyclosporine levels
	Phenytoin, phenobarbital and carbamazepine: Decrease levels of cyclosporine
	Grapefruit juice: Increases absorption of cyclosporine

IBD: Inflammatory bowel disease; NSAIDs: Nonsteroidal anti-inflammatory drugs; 6-TGN: 6-thioguanine nucleotide; TPMT: Thiopurine S-methyltransferase; INR: International normalised ratio.

Table 4 Live and attenuated vaccines

Live	Attenuated
Anthrax	Hepatitis B
Intranasal influenza	Human papilloma virus
Measles-mumps-rubella	Influenza
Polio oral vaccine	Pneumococcal
Small pox
Tuberculosis BCG
Typhoid
Varicella
Yellow fever

BCG: Bacille Calmette-Guerin.