Management of Inflammatory Bowel Diseases in Special Populations: Obese, Old, or Obstetric

Abstract

The epidemiology of inflammatory bowel disease (IBD) is progressively evolving impacting the type of patients with IBD we will see in clinical practice. In this review, we discuss specific challenges and solutions in the management of (1) obese, (2) older and (3) obstetric (pregnant) patients with IBD. With the global obesity epidemic, almost 1 in 3 patients with IBD are obese. Obesity is associated with greater difficulty in achieving remission, higher risk of disease relapse and higher burden and costs of hospitalization in patients with IBD. Obese patients also have inferior response to biologic therapy related to altered pharmacokinetics and obesity-mediated chronic inflammation. Surgical management of obese patients with IBD is also challenging. Similar to obesity, the prevalence of IBD in older patients is rising and it is anticipated that almost one-third of patients with IBD will be older than 60 years within the next decade. Older patients present unique diagnostic and therapeutic dilemmas, and management of these individuals warrants careful consideration of the risks of disease-related versus treatment-related complications, non-IBD-related extra-intestinal complications (eg, cardiovascular disease, malignancy), in the context of individual values, preferences, functional status and comorbidities. With evolving therapeutics, medical management of IBD surrounding pregnancy continues to be challenging. Overall, the management of pregnant patients requires a pro-active, multidisciplinary approach, with an emphasis on optimal disease control not just during, but prior to pregnancy. This often involves continuation of highly effective therapies, of which the vast majority are safe during pregnancy and breastfeeding, resulting in a reduction of risk of adverse maternal fetal outcomes.

Keywords: Body Weight; Crohn's Disease; Elderly; Pregnancy.

Figure 1:

Challenges and proposed solutions in the management of obese patients with IBD. While obesity may negatively both weight-based and fixed-dose therapies, we believe the impact may be more profound with fixed-dose therapies. Whether a similar negative effect of obesity on response to targeted small molecule inhibitors, such as tofacitinib, is unclear. Pharmacokinetically, the clearance of tofacitinib is not affected by body weight. Weight-appropriate dosing refers to dosing infliximab based on actual body weight.

Figure 2:

Approach to management of older patients with IBD. Corticosteroid-dependence implies need for >1–2 corticosteroid courses per year. Since there is only modest correlation between symptoms and presence of active inflammation in patients with CD, particularly small bowel disease, we suggest objective confirmation of inflammation in symptomatic patients, with either serum or stool biomarkers or if needed, on endoscopy or active inflammation on imaging.

Figure 3:

Preconception checklist when contemplating pregnancy in patients with IBD