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Age Disparities in the Use of Steroid-sparing Therapy for Inflammatory Bowel Disease

Govani, Shail M. MD, MSc*,†; Wiitala, Wyndy L. PhD; Stidham, Ryan W. MD, MSc*; Saini, Sameer D. MD, MSc*,†,§; Hou, Jason K. MD, MS; Feagins, Linda A. MD; Sussman, Jeremy B. MD, MSc*,‡,§; Higgins, Peter D. R. MD, PhD, MSc*; Waljee, Akbar K. MD, MSc*,‡,§

doi: 10.1097/MIB.0000000000000817
Original Clinical Articles

Background: Corticosteroids are effective rescue therapies for patients with inflammatory bowel disease (IBD), but have significant side effects, which may be amplified in the growing population of elderly patients with IBD. We aimed to compare the use of steroids and steroid-sparing therapies (immunomodulators and biologics) and rates of complications among elderly (≥65) and younger patients in a national cohort of veterans with IBD.

Methods: We used national Veterans Health Administrative data to conduct a retrospective study of veterans with IBD between 2002 and 2010. Medications and the incidence of complications were obtained from the Veterans Health Administrative Decision Support Systems. Multivariate logistic regression accounting for facility-level clustering was used to identify predictors of use of steroid-sparing medications.

Results: We identified 30,456 veterans with IBD. Of these, 94% were men and 40% were more than 65, and 32% were given steroids. Elderly veterans were less likely to receive steroids (23.8% versus 38.3%, P < 0.001) and were less likely to be prescribed steroid-sparing medications (25.5% versus 46.9%, respectively, P < 0.001). In multivariate analysis controlling for sex, age <65 (odds ratio, 2.19; 95% CI, 1.54–3.11) and gastroenterology care (odds ratio, 8.42; 95% CI, 6.18–11.47) were associated with initiation of steroid-sparing medications. After starting steroids, fracture rates increased in the elderly patients with IBD, whereas increases in venous thromboembolism and infections after starting steroids affected both age groups.

Conclusions: Elderly veterans are less likely to receive steroids and steroid-sparing medications than younger veterans; elderly patients exposed to steroids were more likely to have fractures than the younger population.

*Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan;

VA Ann Arbor Healthcare System, Ann Arbor, Michigan;

VA Center for Clinical Management Research, Ann Arbor, Michigan;

§Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan;

Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Internal Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; and

Division of Gastroenterology and Hepatology, Department of Internal Medicine, VA North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas.

Address correspondence to: Shail M. Govani, MD, MSc, Department of Internal Medicine, 2215 Fuller Road, Room 111D, Ann Arbor, MI 48105 (e-mail: shailg@umich.edu).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.ibdjournal.org).

A. K. Waljee's research is funded by a VA HSR&D CDA-2 Career Development Award 1IK2HX000775. J. K. Hou's research is funded by the VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (#CIN 13-413), at the Michael E. DeBakey VA Medical Center, Houston, TX. J. B. Sussman is supported by VA CDA 13-021. The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

The authors have no conflict of interest to disclose.

Received December 7, 2015

Accepted March 15, 2016

© Crohn's & Colitis Foundation
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