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Incidence and Treatment of Patients Diagnosed With Inflammatory Bowel Diseases at 60 Years or Older in Sweden

  • Åsa H. Everhov
    Correspondence
    Reprint requests Address requests for reprints to: Åsa Hallqvist Everhov, MD, PhD, Department of Surgery, Stockholm South General Hospital, SE 118 61 Stockholm, Sweden.
    Affiliations
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden

    Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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  • Jonas Halfvarson
    Affiliations
    Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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  • Pär Myrelid
    Affiliations
    Division of Surgery, Department of Clinical and Experimental Medicine, Faulty of Health Sciences, Linköping University and Department of Surgery, County Council of Östergötland Linköping, Sweden
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  • Michael C. Sachs
    Affiliations
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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  • Caroline Nordenvall
    Affiliations
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden

    Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
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  • Jonas Söderling
    Affiliations
    Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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  • Anders Ekbom
    Affiliations
    Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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  • Martin Neovius
    Affiliations
    Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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  • Jonas F. Ludvigsson
    Affiliations
    Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

    Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden

    Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK

    Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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  • Johan Askling
    Affiliations
    Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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  • Ola Olén
    Affiliations
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden

    Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden

    Department of Pediatric Gastroenterology and Nutrition, Sachs' Children and Youth Hospital, Stockholm, Sweden
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Published:November 01, 2017DOI:https://doi.org/10.1053/j.gastro.2017.10.034

      Background & Aims

      Diagnosis of inflammatory bowel diseases (IBD) is increasing among elderly persons (60 years or older). We performed a nationwide population-based study to estimate incidence and treatment of IBD.

      Methods

      We identified all incident IBD cases in Sweden from 2006 through 2013 using national registers and up to 10 matched population comparator subjects. We collected data on the patients’ health care contacts and estimated incidence rates, health service burden, pharmacologic treatments, extra-intestinal manifestations, and surgeries in relation to age of IBD onset (pediatric, <18 years; adults, 18–59 years; elderly, ≥60 years).

      Results

      Of 27,834 persons diagnosed with incident IBD, 6443 (23%) had a first diagnosis of IBD at 60 years or older, corresponding to an incidence rate of 35/100,000 person-years (10/100,000 person-years for Crohn’s disease, 19/100,000 person-years for ulcerative colitis, and 5/100,000 person-years for IBD unclassified). During a median follow-up period of 4.2 years (range, 0–9 years), elderly patients had less IBD-specific outpatient health care but more IBD-related hospitalizations and overall health care use than adult patients with IBD. Compared with patients with pediatric or adult-onset IBD, elderly patients used fewer biologics and immunomodulators but more systemic corticosteroids. Occurrence of extra-intestinal manifestations was similar in elderly and adult patients, but bowel surgery was more common in the elderly (13% after 5 years vs 10% in adults) (P < .001). The absolute risk of bowel surgery was higher in the elderly than in the general population, but in relative terms, the risk increase was larger in younger age groups.

      Conclusions

      In a nationwide cohort study in Sweden, we associated diagnosis of IBD at age 60 years or older with a lower use of biologics and immunomodulators but higher absolute risk of bowel surgery, compared with diagnosis at a younger age. The large differences in pharmacologic treatment of adults and elderly patients are not necessarily because of a milder course of disease and warrant further investigation.

      Keywords

      Abbreviations used in this paper:

      CD (Crohn’s disease), CI (confidence interval), HR (hazard ratio), IBD (inflammatory bowel disease), IBD-U (inflammatory bowel disease unclassified), ICD (International Classification of Disease), IR (incidence rate), IRR (incidence rate ratio), UC (ulcerative colitis)
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      References

        • Sturm A.
        • Maaser C.
        • Mendall M.
        • et al.
        European Crohn's and Colitis Organisation topical review on IBD in the elderly.
        J Crohn's Colitis. 2017; 11: 263-273
      1. United Nations, Department of Economic and Social Affairs. World population prospects volume II: demographic profiles. April 24, 2016. Available at: http://esa.un.org/unpd/wpp/Publications/Files/WPP2015_Volume-II-Demographic-Profiles.pdf.

        • Molodecky N.A.
        • Soon I.S.
        • Rabi D.M.
        • et al.
        Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review.
        Gastroenterology. 2012; 142 (quiz e30): 46-54.e42
        • Vind I.
        • Riis L.
        • Jess T.
        • et al.
        Increasing incidences of inflammatory bowel disease and decreasing surgery rates in Copenhagen City and County, 2003-2005: a population-based study from the Danish Crohn colitis database.
        Am J Gastroenterol. 2006; 101: 1274-1282
        • Sincic B.M.
        • Vucelic B.
        • Persic M.
        • et al.
        Incidence of inflammatory bowel disease in Primorsko-goranska County, Croatia, 2000-2004: a prospective population-based study.
        Scand J Gastroenterol. 2006; 41: 437-444
        • Abakar-Mahamat A.
        • Filippi J.
        • Pradier C.
        • et al.
        Incidence of inflammatory bowel disease in Corsica from 2002 to 2003.
        Gastroenterol Clin Biol. 2007; 31: 1098-1103
        • Nerich V.
        • Monnet E.
        • Etienne A.
        • et al.
        Geographical variations of inflammatory bowel disease in France: a study based on national health insurance data.
        Inflamm Bowel Dis. 2006; 12: 218-226
        • Ott C.
        • Obermeier F.
        • Thieler S.
        • et al.
        The incidence of inflammatory bowel disease in a rural region of Southern Germany: a prospective population-based study.
        Eur J Gastroenterol Hepatol. 2008; 20: 917-923
        • Wilson J.
        • Hair C.
        • Knight R.
        • et al.
        High incidence of inflammatory bowel disease in Australia: a prospective population-based Australian incidence study.
        Inflamm Bowel Dis. 2010; 16: 1550-1556
        • Gearry R.B.
        • Richardson A.
        • Frampton C.M.
        • et al.
        High incidence of Crohn's disease in Canterbury, New Zealand: results of an epidemiologic study.
        Inflamm Bowel Dis. 2006; 12: 936-943
        • Jeuring S.F.
        • van den Heuvel T.R.
        • Zeegers M.P.
        • et al.
        Epidemiology and long-term outcome of inflammatory bowel disease diagnosed at elderly age-an increasing distinct entity?.
        Inflamm Bowel Dis. 2016; 22: 1425-1434
        • Lakatos P.L.
        • David G.
        • Pandur T.
        • et al.
        IBD in the elderly population: results from a population-based study in Western Hungary, 1977-2008.
        J Crohns Colitis. 2011; 5: 5-13
        • Charpentier C.
        • Salleron J.
        • Savoye G.
        • et al.
        Natural history of elderly-onset inflammatory bowel disease: a population-based cohort study.
        Gut. 2014; 63: 423-432
        • Norgard B.M.
        • Nielsen J.
        • Fonager K.
        • et al.
        The incidence of ulcerative colitis (1995-2011) and Crohn's disease (1995-2012) - based on nationwide Danish registry data.
        J Crohns Colitis. 2014; 8: 1274-1280
        • Bitton A.
        • Vutcovici M.
        • Patenaude V.
        • et al.
        Epidemiology of inflammatory bowel disease in Quebec: recent trends.
        Inflamm Bowel Dis. 2014; 20: 1770-1776
        • Benchimol E.I.
        • Manuel D.G.
        • Guttmann A.
        • et al.
        Changing age demographics of inflammatory bowel disease in Ontario, Canada: a population-based cohort study of epidemiology trends.
        Inflamm Bowel Dis. 2014; 20: 1761-1769
        • Kim H.J.
        • Hann H.J.
        • Hong S.N.
        • et al.
        Incidence and natural course of inflammatory bowel disease in Korea, 2006-2012: a nationwide population-based study.
        Inflamm Bowel Dis. 2015; 21: 623-630
        • Björnsson S.
        • Tryggvason F.
        • Jonasson J.G.
        • et al.
        Incidence of inflammatory bowel disease in Iceland 1995-2009. A nationwide population-based study.
        Scand J Gastroenterol. 2015; 50: 1368-1375
        • Ng S.C.
        • Tang W.
        • Ching J.Y.
        • et al.
        Incidence and phenotype of inflammatory bowel disease based on results from the Asia-pacific Crohn's and Colitis Epidemiology study.
        Gastroenterology. 2013; 145: 158-165.e2
        • Bernstein C.N.
        • Wajda A.
        • Svenson L.W.
        • et al.
        The epidemiology of inflammatory bowel disease in Canada: a population-based study.
        Am J Gastroenterol. 2006; 101: 1559-1568
        • Herrinton L.J.
        • Liu L.
        • Lewis J.D.
        • et al.
        Incidence and prevalence of inflammatory bowel disease in a Northern California managed care organization, 1996-2002.
        Am J Gastroenterol. 2008; 103: 1998-2006
        • Romberg-Camps M.J.
        • Hesselink-van de Kruijs M.A.
        • Schouten L.J.
        • et al.
        Inflammatory bowel disease in South Limburg (the Netherlands) 1991-2002: incidence, diagnostic delay, and seasonal variations in onset of symptoms.
        J Crohns Colitis. 2009; 3: 115-124
        • Rönnblom A.
        • Samuelsson S.M.
        • Ekbom A.
        Ulcerative colitis in the county of Uppsala 1945-2007: incidence and clinical characteristics.
        J Crohns Colitis. 2010; 4: 532-536
        • Loftus C.G.
        • Loftus Jr., E.V.
        • Harmsen W.S.
        • et al.
        Update on the incidence and prevalence of Crohn's disease and ulcerative colitis in Olmsted County, Minnesota, 1940-2000.
        Inflamm Bowel Dis. 2007; 13: 254-261
        • Lapidus A.
        Crohn's disease in Stockholm County during 1990-2001: an epidemiological update.
        World J Gastroenterol. 2006; 12: 75-81
        • Shivashankar R.
        • Tremaine W.J.
        • Harmsen W.S.
        • et al.
        Incidence and prevalence of Crohn's disease and ulcerative colitis in Olmsted County, Minnesota from 1970 through 2010.
        Clin Gastroenterol Hepatol. 2017; 15: 857-863
        • Ruel J.
        • Ruane D.
        • Mehandru S.
        • et al.
        IBD across the age spectrum: is it the same disease?.
        Nat Rev Gastroenterol Hepatol. 2014; 11: 88-98
        • Fries W.
        • Viola A.
        • Manetti N.
        • et al.
        Disease patterns in late-onset ulcerative colitis: results from the IG-IBD “AGED study”.
        Dig Liver Dis. 2017; 49: 17-23
        • Nguyen G.C.
        • Bernstein C.N.
        • Benchimol E.I.
        Risk of surgery and mortality in elderly-onset inflammatory bowel disease: a population-based cohort study.
        Inflamm Bowel Dis. 2017; 23: 218-223
        • Nimmons D.
        • Limdi J.K.
        Elderly patients and inflammatory bowel disease.
        World J Gastrointest Pharmacol Ther. 2016; 7: 51-65
        • Taleban S.
        • Colombel J.F.
        • Mohler M.J.
        • et al.
        Inflammatory bowel disease and the elderly: a review.
        J Crohns Colitis. 2015; 9: 507-515
        • Duricova D.
        • Burisch J.
        • Jess T.
        • et al.
        Age-related differences in presentation and course of inflammatory bowel disease: an update on the population-based literature.
        J Crohns Colitis. 2014; 8: 1351-1361
        • Ananthakrishnan A.N.
        • Shi H.Y.
        • Tang W.
        • et al.
        Systematic review and meta-analysis: phenotype and clinical outcomes of older-onset inflammatory bowel disease.
        J Crohns Colitis. 2016; 10: 1224-1236
        • Gisbert J.P.
        • Chaparro M.
        Systematic review with meta-analysis: inflammatory bowel disease in the elderly.
        Aliment Pharmacol Ther. 2014; 39: 459-477
        • Parian A.
        • Ha C.Y.
        Older age and steroid use are associated with increasing polypharmacy and potential medication interactions among patients with inflammatory bowel disease.
        Inflamm Bowel Dis. 2015; 21: 1392-1400
        • Lobaton T.
        • Ferrante M.
        • Rutgeerts P.
        Efficacy and safety of anti-TNF therapy in elderly patients with inflammatory bowel disease.
        Aliment Pharmacol Ther. 2015; 42: 441-451
        • Brassard P.
        • Bitton A.
        • Suissa A.
        • et al.
        Oral corticosteroids and the risk of serious infections in patients with elderly-onset inflammatory bowel diseases.
        Am J Gastroenterol. 2014; 109 (quiz 1803): 1795-1802
        • Hou J.K.
        • Feagins L.A.
        • Waljee A.K.
        Characteristics and behavior of elderly-onset inflammatory bowel disease: a multi-center US study.
        Inflamm Bowel Dis. 2016; 22: 2200-2205
        • Nguyen G.C.
        • Sheng L.
        • Benchimol E.I.
        Health Care utilization in elderly onset inflammatory bowel disease: a population-based study.
        Inflamm Bowel Dis. 2015; 21: 777-782
        • Ludvigsson J.F.
        • Andersson E.
        • Ekbom A.
        • et al.
        External review and validation of the Swedish national inpatient register.
        BMC Publ Health. 2011; 11: 450
        • Wallerstedt S.M.
        • Wettermark B.
        • Hoffmann M.
        The first decade with the Swedish Prescribed Drug Register - a systematic review of the output in the scientific literature.
        Basic Clin Pharmacol Toxicol. 2016; 119: 464-469
        • Ludvigsson J.F.
        • Otterblad-Olausson P.
        • Pettersson B.U.
        • et al.
        The Swedish personal identity number: possibilities and pitfalls in healthcare and medical research.
        Eur J Epidemiol. 2009; 24: 659-667
        • Wettermark B.
        • Hammar N.
        • Fored C.M.
        • et al.
        The new Swedish Prescribed Drug Register–opportunities for pharmacoepidemiological research and experience from the first six months.
        Pharmacoepidemiol Drug Safety. 2007; 16: 726-735
        • Neovius M.
        • Sundstrom A.
        • Simard J.
        • et al.
        Small-area variations in sales of TNF inhibitors in Sweden between 2000 and 2009.
        Scand J Rheumatol. 2011; 40: 8-15
        • Ludvigsson J.F.
        • Almqvist C.
        • Bonamy A.K.
        • et al.
        Registers of the Swedish total population and their use in medical research.
        Eur J Epidemiol. 2016; 31: 125-136
        • Jakobsson G.L.
        • Sternegard E.
        • Olen O.
        • et al.
        Validating inflammatory bowel disease (IBD) in the Swedish National Patient Register and the Swedish Quality Register for IBD (SWIBREG).
        Scand J Gastroenterol. 2017; 52: 216-221
        • Harbord M.
        • Annese V.
        • Vavricka S.R.
        • et al.
        The first European evidence-based consensus on extra-intestinal manifestations in inflammatory bowel disease.
        J Crohns Colitis. 2016; 10: 239-254
        • Sjöberg D.
        • Holmstrom T.
        • Larsson M.
        • et al.
        Incidence and natural history of ulcerative colitis in the Uppsala region of Sweden 2005-2009-results from the IBD cohort of the Uppsala Region (ICURE).
        J Crohns Colitis. 2013; 7: e351-e357
        • Sjöberg D.
        • Holmstrom T.
        • Larsson M.
        • et al.
        Incidence and clinical course of Crohn's disease during the first year - results from the IBD Cohort of the Uppsala Region (ICURE) of Sweden 2005-2009.
        J Crohns Colitis. 2014; 8: 215-222
        • Shivananda S.
        • Lennard-Jones J.
        • Logan R.
        • et al.
        Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD).
        Gut. 1996; 39: 690-697
        • Khalili H.
        • Huang E.S.
        • Ananthakrishnan A.N.
        • et al.
        Geographical variation and incidence of inflammatory bowel disease among US women.
        Gut. 2012; 61: 1686-1692
        • Leddin D.
        • Tamim H.
        • Levy A.R.
        Decreasing incidence of inflammatory bowel disease in eastern Canada: a population database study.
        BMC Gastroenterol. 2014; 14: 140
        • Ananthakrishnan A.N.
        • McGinley E.L.
        • Binion D.G.
        Inflammatory bowel disease in the elderly is associated with worse outcomes: a national study of hospitalizations.
        Inflamm Bowel Dis. 2009; 15: 182-189
        • Juneja M.
        • Baidoo L.
        • Schwartz M.B.
        • et al.
        Geriatric inflammatory bowel disease: phenotypic presentation, treatment patterns, nutritional status, outcomes, and comorbidity.
        Dig Dis Sci. 2012; 57: 2408-2415
        • del Val J.H.
        Old-age inflammatory bowel disease onset: a different problem?.
        World J Gastroenterol. 2011; 17 (2734–279)
        • Colombel J.F.
        • Sandborn W.J.
        • Reinisch W.
        • et al.
        Infliximab, azathioprine, or combination therapy for Crohn's disease.
        N Engl J Med. 2010; 362: 1383-1395
        • Rutgeerts P.
        • Sandborn W.J.
        • Feagan B.G.
        • et al.
        Infliximab for induction and maintenance therapy for ulcerative colitis.
        N Engl J Med. 2005; 353: 2462-2476
        • Kurti Z.
        • Vegh Z.
        • Golovics P.A.
        • et al.
        Nationwide prevalence and drug treatment practices of inflammatory bowel diseases in Hungary: a population-based study based on the National Health Insurance Fund database.
        Dig Liver Dis. 2016; 48: 1302-1307
        • Kumar V.
        • Shah Y.
        • Patel D.
        • et al.
        Elderly-onset and adult-onset ulcerative colitis are more similar than previously reported in a nationwide cohort.
        Dig Dis Sci. 2017; 62: 2857-2862
        • Lewis J.D.
        • Scott F.I.
        • Brensinger C.M.
        • et al.
        Reduced mortality rates with anti-tumor necrosis factor alpha directed therapy when compared to prolonged corticosteroid therapy for inflammatory bowel disease.
        Gastroenterology. 2017; 152 (Suppl 1.): S64-S65