Supplementary Table 1 | IBD medication monitoring for elderly IBD patients 1–7
IBD medication Potential adverse events Monitoring strategy
5-ASAs
Nephrotoxicity
 Routine monitoring of creatinine
 Potential use with caution for patients with underlying
severe renal disease
Diarrhea/exacerbation of
 Paradoxical hypersensitivity diarrhea can occur in
colitis symptoms
mesalamine treated patients
 If persistent symptoms, trial of medication
discontinuation or switching agents (particularly with
sulfasalazine)
Corticosteroids Serious infection
 Construct steroid-sparing exit strategy with first steroid
taper
 Avoid repeated steroid tapers
 No maintenance steroids
 Vaccinations (influenza, pneumonia, zoster if
appropriate)
Osteopenia/osteoporosis
 Calcium + Vitamin D supplementation (recommended
1000-1200mg of calcium daily, 400-800 IU of Vitamin
D daily)
 Consider 25-OH Vitamin D testing and repletion if low
 Regular weight-bearing exercise
 Bone densitometry – recommended for patients >50
years, > 3 months of steroid exposure
Avascular necrosis
 If persistent joint pain of hips, knees, shoulders,
consider imaging with magnetic resonance imaging
(MRI) or bone scan
Glaucoma/cataracts
 Annual ophthalmologic exams
Steroid-induced
 Routine blood glucose monitoring, particularly if prediabetes/hyperglycemia
existing history of diabetes
 Maintain tight glycemic control with oral hypoglycemic
± insulin
 Registered dietitian consultation
Myopathy
 Monitor for proximal muscle weakness
 Routine physical activity, consider physical therapy and
occupational therapy consultation if prolonged steroid
use
Hypertension
 Routine blood pressure checks, consult with primary
care physician for adjustments to medical therapy if
persistently elevated
Thiopurines
Serious infection
 Vaccinations
 Hold immunosuppression if severe infection requiring
hospitalization
Myelosuppression
 Thiopurine methyltransferase (TPMT) testing prior to
thiopurine initiation
 Review medication list for potential interactions (e.g.
allopurinol)
 Routine complete blood count (CBC) monitoring every
1-3 months
 Thiopurine metabolite testing
Hepatotoxicity
 TPMT testing
 Routine liver function monitoring every 1-3 months
 Thiopurine metabolite testing – consider dose-adjusted
IMM plus allopurinol therapy
Skin cancer (nonmelanoma)
Lymphoma
Ciprofloxacin
Achilles tendinitis/tendon
rupture
Clostridium difficile
Anti-TNF
agents
Serious infection
Immunogenicity, loss of
response
Anti-TNF induced lupus
Psoriasis
Congestive heart failure
(CHF)
 Routine dermatologic evaluations
 Appropriate sun protection, including scalp and eye
protection
 No screening mechanism, but monitor for “B”symptoms: fevers, night sweats, unintentional weight
loss; also, unexplained fatigue and weakness
 Routine office visits, full physical exam to check for
peripheral adenopathy
 Routine CBC monitoring for persistent cytopenias
 Stop therapy if new diagnosis, consult with oncology
first prior to starting therapy if prior history of
lymphoma
 Avoid concomitant use - Increased risk in elderly on
concomitant steroids
 Check for pain with palpation along Achilles tendon,
particularly with plantar flexion
 MRI or ultrasound if high clinical suspicion
 Increased risk of C. difficile infection among the elderly
on antibiotics
 Low threshold for testing if increased diarrheal
symptoms (regardless of antibiotic exposure)
 Initial treatment with metronidazole for mild first
episode, but low threshold to escalate to vancomycin if
non-response
 Vancomycin for moderate to severe disease (with or
without IV metronidazole)
 Vaccinations
 If severe symptoms, consider evaluation for atypical or
opportunistic infections such as histoplasmosis,
coccidiomycosis or Pneumocystis jiroveci
 Tuberculosis screening prior to anti-TNF initiation
(indeterminate result may occur while on chronic
steroids)
 Hepatitis B testing (surface antigen and antibody)
 Anti-TNF level and antibody testing
 Dose adjustment or switch depending on presence or
absence of antibodies
 Smoking cessation counseling
 Monitor for swollen, painful, stiff joints
 Testing for drug-induced lupus: anti-nuclear antibodies
(ANA), double-stranded DNA antibody (dsDNA), antihistone antibodies
 Rheumatology consultation
 Discontinue or switch anti-TNF agents
 Dermatology consultation if progressive skin lesions
present
 Limited affected area or mild symptoms  trial of
topical therapy first
 If extensive affected area or severe psoriasis, switch
or discontinued anti-TNF
 Possible role for ustekinumab
 Contraindicated for Class III or IV heart failure
 Pre-treatment consultation with cardiology for patients
with class I or II heart failure or pre-disposing
Demyelinating disorders
Skin cancers (melanoma)
Malignancy
conditions to CHF
 Contraindicated for patients with central demyelinating
conditions
 Consult with neurologist for patients with possible
history of demyelinating disorders
 Neurology referral if symptoms if ataxia, paresthesias,
etc. with no other explainable cause
 Routine dermatologic evaluations
 Appropriate sun protection, including scalp and eye
protection
 Continue routine cancer screening programs – e.g.
breast, colon and prostate (if appropriate)
 Consultation with oncology prior to initiation if current,
recent or remote history if malignancy
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