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Older patients with Crohn’s may benefit from early combined immunosuppression
Using an early combined immunosuppression strategy in older patients with Crohn’s disease does not appear to cause additional treatment-related complications, according to a post-hoc analysis of REACT, a cluster-randomized trial.
Siddharth Singh, MD, of the division of gastroenterology and division of biomedical informatics at the University of California San Diego, and colleagues wrote in Alimentary Pharmacology & Therapeutics that differences between older and younger patients have led to a limited understanding of the risks and benefits of all the treatment strategies in CD.
“In younger patients at high risk of disease complications and relative paucity of concomitant comorbidity, aggressive therapy with combination of biologics and antimetabolites is preferred,” they wrote. “However, it is unclear whether this strategy can be directly extrapolated to older patients who may be more susceptible to treatment-related complications and non-Crohn's disease-related complications associated with comorbidity.”
Singh and colleagues explored the impact of age on risk for CD-related complications in patients treated with early combined immunosuppression compared with conventional management. In the combined arm, patients with failure to achieve clinical remission within 4 to 12 weeks of corticosteroids received a combination of anti-TNF plus antimetabolite and escalated therapy in a stepwise algorithm.
Researchers compared the efficacy, defined as time to major adverse outcome (CD-related surgery, hospitalization or serious complications; steroid-free remission), and safety outcomes at 24 months between patients aged less than 60 years vs. patients aged at least 60 years. Of 1,981 patients, 311 were aged at least 60 years. Investigators randomly assigned 173 of those patients to early combined therapy and 138 to conventional therapy.
Over 24 months of follow-up, 10% of older patients developed CD-related complications — 6.4% in the combined arm vs. 14.5% in the conventional arm. Fourteen patients died (combined arm, 3.5% vs. conventional arm, 5.8%).
Singh and colleagues found that there was no difference between younger and older patients in risk for achieving corticosteroid-free clinical remission (< 60 years, early combined immunosuppression [72.6%] vs. conventional management [64.4%]; RR = 1.06; 95% CI, 0.98–1.15 vs. 60 years, early combined immunosuppression [74.8%] vs. conventional management [63.0%]; RR = 1.09, 95% CI, 0.90–1.33). The same was true for time to major adverse outcome (< 60 years, HR = 0.71; 95% CI, 0.53–0.96 vs. 60 years, HR = 0.69, 95% CI, 0.31–1.51) with early combined immunosuppression compared with conventional therapy.
Singh and colleagues wrote that there was no evidence to show that a treatment strategy of early combined immunosuppression based on anti-TNF is less effective in older patients than in younger patients with CD.
“In selected older patients with suboptimal disease control, an algorithmic treatment stepup strategy may be considered to decrease treatment disutility and avoid persistence on chronic corticosteroids,” they concluded. “Future studies focusing on older patients at higher risk of disease complications and designed to evaluate optimally tailored treatment approaches and treatment targets and to evaluate the impact of nonTNF alpha biologics and targeted small molecules are warranted.” – by Alex Young
Disclosures: Singh reports receiving research support from AbbVie and Pfizer, consulting fees from AbbVie and Takeda outside the submitted work. Please see the full study for all other authors’ relevant financial disclosures.