GP-04 Are Thiopurines Too Risky? Thiopurine Use, Monitoring, and Adverse Effects in Elderly Patients with IBD in a Statewide Hospital System
Start Date
31-3-2023 10:30 AM
End Date
31-3-2023 12:30 PM
Document Type
Poster
Abstract
Background: Recent FDA approval of newer biologics for Inflammatory Bowel Disease (IBD) monotherapy with significant efficacy and better safety profiles brings into question thiopurine use in IBD treatment algorithms. Thiopurines (azathioprine and mercaptopurine) have been considered convenient and affordable oral long-term maintenance therapy options for IBD by increasing the likelihood of corticosteroid-free remission, increasing anti-TNF drug levels, and reducing anti-TNF antibody formation. However, thiopurines are associated with adverse effects including increased risk of infections, lymphoproliferative disorders, and cancers. Patients over the age of 65 are at higher risk of developing these life-threating complications when compared to thiopurine users under 50 years of age. In recent years, thiopurine-related adverse outcomes have led to AGA clinical practice updates suggesting that thiopurines should only be considered on an individual basis for elderly patients, and new initiation of thiopurines should be done with caution in this age group. In order to detect lymphoproliferative disorders early, Complete Blood Count (CBC) should be checked on a 3 month basis for maintenance therapy, and more frequently within the first months after initiation. Inadequate monitoring has led to hospitalizations, co-morbidities, and deaths.
Methods: A retrospective chart review of patients aged 60 or older seen within the Prisma Health system in the past 12 months were identified by diagnoses of Crohn’s Disease, Ulcerative colitis, or indeterminate colitis. Days since last CBC was calculated and categorized within last 30, 60, 90, 180, or 365 days. CBCs were examined for dyscrasias associated with thiopurine use. Patients received a phone survey to determine extent of medication education and to confirm use and demographics. Exclusion criteria were no available office or hospital encounters within 2 years, patients who have discontinued the medication or who are deceased.
Results: 123 patients were included in the study. The average number of days from last CBC for all patients was 153 days. 55% of patients identified had a CBC that was longer than 90 days and 9.7% were over 1 year since last CBC. Several lab abnormalities were identified with most frequent being lymphopenia (33.3%), Anemia (25.2%), and thrombocytopenia (3.2%). Leucopenia (3.2%) and Neutropenia (2.4%) were also observed.
Conclusions: Based on these data, thiopurines are still prevalently utilized for IBD maintenance in the elderly population. CBC monitoring does not occur on the recommended 3-month intervals, and some patients may go over a year without monitoring. Unfortunately, various lab abnormalities including more serious leukopenia and neutropenia were observed, and patients were frequently unaware of these abnormalities and the need for frequent screening when surveyed. With the lack of routine CBC monitoring, the question arises as to if thiopurines are still a suitable option for elderly patients with IBD when newer biologics are now available with greater efficacy and safety profiles
GP-04 Are Thiopurines Too Risky? Thiopurine Use, Monitoring, and Adverse Effects in Elderly Patients with IBD in a Statewide Hospital System
Background: Recent FDA approval of newer biologics for Inflammatory Bowel Disease (IBD) monotherapy with significant efficacy and better safety profiles brings into question thiopurine use in IBD treatment algorithms. Thiopurines (azathioprine and mercaptopurine) have been considered convenient and affordable oral long-term maintenance therapy options for IBD by increasing the likelihood of corticosteroid-free remission, increasing anti-TNF drug levels, and reducing anti-TNF antibody formation. However, thiopurines are associated with adverse effects including increased risk of infections, lymphoproliferative disorders, and cancers. Patients over the age of 65 are at higher risk of developing these life-threating complications when compared to thiopurine users under 50 years of age. In recent years, thiopurine-related adverse outcomes have led to AGA clinical practice updates suggesting that thiopurines should only be considered on an individual basis for elderly patients, and new initiation of thiopurines should be done with caution in this age group. In order to detect lymphoproliferative disorders early, Complete Blood Count (CBC) should be checked on a 3 month basis for maintenance therapy, and more frequently within the first months after initiation. Inadequate monitoring has led to hospitalizations, co-morbidities, and deaths.
Methods: A retrospective chart review of patients aged 60 or older seen within the Prisma Health system in the past 12 months were identified by diagnoses of Crohn’s Disease, Ulcerative colitis, or indeterminate colitis. Days since last CBC was calculated and categorized within last 30, 60, 90, 180, or 365 days. CBCs were examined for dyscrasias associated with thiopurine use. Patients received a phone survey to determine extent of medication education and to confirm use and demographics. Exclusion criteria were no available office or hospital encounters within 2 years, patients who have discontinued the medication or who are deceased.
Results: 123 patients were included in the study. The average number of days from last CBC for all patients was 153 days. 55% of patients identified had a CBC that was longer than 90 days and 9.7% were over 1 year since last CBC. Several lab abnormalities were identified with most frequent being lymphopenia (33.3%), Anemia (25.2%), and thrombocytopenia (3.2%). Leucopenia (3.2%) and Neutropenia (2.4%) were also observed.
Conclusions: Based on these data, thiopurines are still prevalently utilized for IBD maintenance in the elderly population. CBC monitoring does not occur on the recommended 3-month intervals, and some patients may go over a year without monitoring. Unfortunately, various lab abnormalities including more serious leukopenia and neutropenia were observed, and patients were frequently unaware of these abnormalities and the need for frequent screening when surveyed. With the lack of routine CBC monitoring, the question arises as to if thiopurines are still a suitable option for elderly patients with IBD when newer biologics are now available with greater efficacy and safety profiles