Anti-TNF Therapy in Elderly Patients with Inflammatory Bowel Disease in a Tuberculosis-Endemic Country

Background: Anti-tumor necrosis factor (anti-TNF) drugs have been the mainstay therapy for moderate to severe inflammatory bowel disease (IBD) over the past 25 years and have substantially modified the course of the disease. Nevertheless, these drugs are known to increase the risk of serious opportunistic infections and malignancies, especially in the elderly population. Brazil is ranked among the 30 countries with the highest incidence of TB in the world and data on the safety of anti-TNF drugs in this population are scarce. Our aim was to evaluate the frequency of serious infections in elderly IBD patients treated with anti-TNF. Methods: This was a cross-sectional and observational study in an IBD reference center in São Paulo, Brazil. Results: Ninety-two patients over 60 years of age, using an anti-TNF (infliximab, adalimumab or certolizumab) were included. Infliximab was prescribed for 68 (73.9%) patients, while adalimumab for 24 (26%) subjects. None of them received certolizumab. The mean age of IBD diagnosis was 66.5 (SD 5.3) years. Twenty-one (22.8%) patients were diagnosed with ulcerative colitis and the majority of them had pancolitis (76.1%). Crohn’s disease location was ileocolonic in 39 (42.3%) patients, ileal in 19 (20.6%) and colonic in 12 (13%) patients. Forty-five (48.9%) patients had stenosing or fistulizing behavior. The mean duration of IBD was 19 years. Nineteen (20.6%) patients were current or previous smokers. One third of cases had a history of intestinal surgery before the introduction of anti-TNF. The main comorbidities were hypertension, dyslipidemia and diabetes mellitus in 41, 25 and 18 patients, respectively. The Charlson comorbidity index was calculated and in 78.2% of cases the score was less than 3 (mild) and in 21.8% of patients the index was greater than 3 (moderate or high). Concomitant immunosuppression was prescribed in 28 (30.4%) patients. Endoscopic healing defined by Mayo score ≤1 or absence of ulcers was achieved in 57 (61.9%) patients. Serious infection, defined as infections requiring hospitalization, was diagnosed in 13 (14%) subjects. Five (5.4%) patients developed active tuberculosis during anti-TNF therapy. Conclusions: In conclusion, TB remains a significant health problem in IBD patients, especially in high-prevalent areas and in patients on anti-TNF therapy. Compared with our previous results, the prevalence of TB reactivation in elderly patients seems higher than in younger patients under the same treatment. A personalized treatment in high risk TB countries is essential and should consider individual characteristics and local epidemiological factors.