Purpose: Chronic inflammation, including Crohn's disease (CD), is associated with hypercoagulability and increased rates of vascular disease and this is especially true in elderly patients. Anti-platelet and anticoagulant therapy has been recommended as a preventive strategy for geriatric patients at risk for complications of atherosclerosis and thrombosis. However, there is concern that aspirin use may cause a worsening of IBD clinical status with disease flare, and anticoagulation may be associated with a worsening of gastrointestinal blood loss. Systematic data describing the relationship of antiplatelet agents and anti-coagulant use with CD activity among elderly CD is limited. Methods: We performed a comprehensive analysis of CD patients age ≥ 65 followed in a tertiary care hospital to determine relationship of CD activity and patients of anti-platelet and anticoagulant therapy. Data was extracted from a comprehensive electronic medical record based on ICD9 coding and indexed terms. CD activity was determined by retrospective chart reviews, with active disease defined by physician global assessment, clinical impression, symptoms of diarrhea and abdominal pain, and endoscopic and/or radiographic evidence of activity. Study duration was 24 months. Patients were labeled as active disease if they had ≥1 relapse during the study period and inactive patients remained in remission the entire time. Results: There were 90 geriatric CD patients identified of whom 32.2% were receiving anti-platelet/anticoagulant therapy. Among these individuals rates of antiplatelet/anticoagulant treatment included: Aspirin - 17.8%; warfarin - 11.1%; cilostazol - 1.1%; clopidogrel - 1.1%; low molecular weight heparin - 1.1%. During the study period 35.6% of the geriatric patients had active CD. The mean age for active CD was 71.4 ± 6.4 (years ± S.D.) and for inactive CD was 72.8 ± 6.8 (years ± S.D), p = NS. Among geriatric CD patients with active CD during the study period, 15.6% were using aspirin, while 19% of inactive geriatric CD were using aspirin. Among active geriatric CD patients, warfarin use was identified in 9.4%, while 12.1% of inactive CD were using warfarin. Conclusion: Aspirin and warfarin use was not associated with a higher likelihood of active CD in geriatric patients. These agents may be underutilized in geriatric patients with CD, who are at high risk of cardio-vascular events due to their chronic inflammation. Prospective studies are warranted in this respect.
Purpose: There is an increase in arterial thrombotic events in the elderly. Comorbid illness associated with chronic inflammation may further increase the risk of an arterial ischemic event, with data suggesting 5 fold increased cardiovascular risk for those over age 70 compared with those under age 55. Antiplatelet therapy with aspirin has been recommended as a preventive strategy for geriatric patients at risk for complications of atherosclerosis and thrombosis. Crohn's disease (CD) is a chronic inflammatory illness of the gastrointestinal tract which can affect any age and increased risk of vascular disease in CD has been identified. Aspirin use has been associated with CD exacerbation and it is unknown if it should be routinely used in CD patients at risk for vascular disease. Systematic data describing the use of aspirin in patients with geriatric CD is limited. Methods: Retrospective descriptive study of all CD patients followed in a 20 hospital system born prior to the year 1944. Data was extracted from a comprehensive electronic medical record (EMR) based on ICD9 coding and indexed terms and we examined all records (inpatient and outpatient) which were available in the study population. Co-morbidity was determined using Charlson's index. Results: There were 150 geriatric CD patients identified in the EMR data analysis. 20% of these individuals were on aspirin therapy. In the geriatric CD cohort, rates of vascular disease were: Coronary artery disease (CAD) - 30.7%; Cerebrovascular disease (CVD) - 13.3%; peripheral vascular disease (PVD) - 8.7%. Patterns of aspirin usage in the CD patients with specific vascular disorders were as follows: CAD - 23.1%; CVD - 35%; PVD - 23.1 %. Next, we compared the rates of co-morbidity using Charlson's index between patients receiving and not receiving aspirin (on aspirin 3.8±3.8, not on aspirin 2.4 ± 2.2; p=0.06). There was no difference in the hospitalization rates for patients on aspirin (3.8±2.3) and those not on aspirin (3.4± 2.6); p= 0.625. Conclusion: In our IBD cohort, geriatric CD patients demonstrated an overall low use of aspirin, which was identified in one fifth of these individuals. Co-morbidity, number of concomitant illnesses and number of hospitalizations, was similar between geriatric CD patients receiving and not receiving aspirin. These data suggests that aspirin may be tolerated and underutilized in the elderly CD population, but prospective studies are warranted.
Purpose: The US population is aging and the burden of patients with geriatric Crohn's disease (CD) is increasing. Studies have suggested that inflammatory bowel disease (IBD) including CD in elderly patients is different from the disease in young patients, arguing for two variant disease phenotypes. Treatment patterns may differ between geriatric and young IBD, with elderly patients receiving medications for concomitant illness and prophylaxis of cardiac, vascular and bone health. Nonsteroidal antiinflammatory drugs (NSAIDs) and hormone replacement therapy (HRT) have been associated with initial onset of IBD and reactivation of quiescent disease in IBD. Data describing NSAIDs and HRT treatment in elderly CD is limited. Methods: We performed a comprehensive analysis of CD patients age ≥ 65 followed in a tertiary care center. We determined patterns of CD activity over an 18 month time period and its relationship with treatment patterns of NSAIDs and HRT therapy. CD activity was categorized by retrospective chart review, with active disease defined by physician global assessment, clinical impression, symptoms of diarrhea and abdominal pain, and endoscopic and/or radiographic evidence of activity. Patients were labeled as active disease if they had ≥ 1 relapse during the study period and inactive patients remained in remission the entire time. Results: There were 90 geriatric CD patients, with 35.6% (n = 32) showing evidence of active CD during the study time period. The mean age for active CD was 71.4 ± 6.4 (years ± S.D.) and for inactive CD was 72.8 ± 6.8 (years ± SD). Among geriatric patients with active CD, 9.4% were on NSAIDs while the inactive CD cohort had 15.5% receiving NSAIDs. Female constituted 54% of the geriatric CD patients (n=49) and HRT was identified in only 7 patients (8% of the total and 14% of the female geriatric cohort). Among female CD patients with active disease 19% were on HRT, while 11% of inactive CD geriatric females were on HRT (p=NS). Conclusion: Our study of geriatric CD patients suggests that use of NSAIDs and HRT did not correlate with increased rates of disease activity during an 18 month time period. Further prospective studies evaluating the use of NSAIDs and HRT in geriatric CD are warranted.
Crohn's disease (CD) patients may be at increased risk for the development of Hodgkin's lymphoma (HL) or non-Hodgkin's lymphoma (NHL), either through exposure to immunosuppressive medications or due to their underlying chronic inflammatory illness. There are limited data regarding the natural history of CD following treatment of lymphoma. We present a series of CD patients who were treated for lymphoma and describe the natural history of their CD following lymphoma treatment. Retrospective case series from three academic referral centers was used. All CD patients with a history of lymphoma were identified. Demographic data, CD medication exposure, and surgical procedures before and after lymphoma treatment were recorded. Nine CD patients with a history of lymphoma were identified. Eight individuals received chemotherapy, while one patient was observed without treatment. Eight patients remained free of lymphoma for a mean of 72.8 months (range 1-276 months). The ninth patient had recurrence of his HL 3 years after lymphoma diagnosis. Following lymphoma treatment, two patients had quiescent CD with no specific therapy. Three patients demonstrated significant clinical relapse of their CD and a fourth patient developed CD after treatment of her lymphoma, which ultimately required long-term immunomodulator therapy with 6-mercaptopurine or methotrexate in the first three patients, and azathioprine in the fourth. Four patients required CD surgery after lymphoma treatment. We report on the clinical course of CD in patients who develop lymphoma. Significant clinical relapse of CD following successful medical treatment of lymphoma occurred frequently in patients with a history of this neoplasm. (Inflamm Bowel Dis 2011)
The incidence of inflammatory bowel disease (IBD; Crohn ' s disease, ulcerative colitis) is highest during the peak reproductive years, hence the increased concern with the safety of IBD drugs during pregnancy. Over the past 11 years, anti-TNF-α antibody therapy has emerged as a treatment approach for refractory IBD patients who have failed to achieve or maintain remission with corticosteroids and immunomodulator agents. The TNF-α inhibitors (anti-TNFs; infliximab, adalimumab, certolizumab pegol) have proven successful in inducing and maintaining remission of moderateto- severe IBD, but recommendations for the use of these compounds during pregnancy have lacked consensus. Balanced against the potential risk of these drugs on the fetus is the well-established fact that high disease activity has been found to poorly affect pregnancy outcomes in IBD, and the potential use of anti-TNF agents may control disease flare and severity during pregnancy. Concerns regarding the effect of anti-TNFs on the pregnancy and fetus have been assuaged by registry data which has demonstrated an overall positive safety record. Both the U.S. Food and Drug Administration and the European Crohns and Colitis Organization categorize anti-TNF agents as safe during pregnancy. New knowledge regarding the physiologic timing of placental transfer of therapeutic antibody subclasses and pegylated antibody fragments from the mother into the fetus has also helped to allay concerns. This review will examine the present state of knowledge regarding the use of anti-TNFs in pregnant women with IBD.
Purpose: Inflammatory bowel disease (IBD; Crohn's disease (CD), ulcerative colitis (UC)) significantly impacts patients' quality of life and stresses psychosocial function. Of particular concern is how illness will affect interpersonal relationships. A major fear of IBD patients is the need for colectomy/ostomy and how this may affect their relationship with significant others and marital status. Currently, there is limited data regarding the impact of severe colitis and colectomy on marital status. We evaluated marriage durability in a cohort of IBD colitis patients following medical and surgical management for severe disease requiring hospitalization. Methods: We conducted a retrospective, observational study of IBD patients at a tertiary referral center. IBD patients were identified with ICD 9 codes and indexed terms from hospital admissions from 2002-2008. De-identified records were reviewed, including hospital course, demographic data, treatment, surgical procedures, out patient follow-up and marital status. Results: Among 184 patients who required hospitalization (UC 86.7%, CD 2.7%, and IC 10.6%) for IBD colitis, 59.2% were married, 3.2% were divorced, and 37.5% were single at the time of hospitalization. Mean age of the married patients was 47.1 years (range 24-79 years) and they were 40.4% female and 59.6% male. Among these married individuals 23.9% required colectomy (69.2% male, 30.8% female). Patients were followed for a mean period of 485.7 days (range 1-1860 days). Among married IBD colitis patients, 10.1% required permanent end-ileostomy and 13.8% had ileoanal reconstruction. Among 109 IBD patients who were married at the time of hospitalization for severe colitis (including individuals who required colectomy/end-ilesotomy), none underwent divorce during the follow-up time period (1-5 years, mean 3.5 years). Conclusion: We report no increase in divorce among a large cohort of married IBD patients who required inpatient management for severe colitis (including a subset with colectomy/ileostomy). Patients with IBD have significant concern that severe colitis and its treatments, especially colectomy/ileostomy, may damage relationships with their spouse. Our data suggests that marriage durability is not adversely affected in IBD patients requiring hospitalization for the management of severe colitis. The impact of IBD colitis and its treatments on patients' psychosocial function, interpersonal relationships and quality of life is an area of clinical investigation which warrants further study.
