Skip Navigation
Skip to contents

Intest Res : Intestinal Research

Search
Advanced Search
IMPACT FACTOR
mobile search button mobile menu button

Articles

Page Path
HOME > Intest Res > Volume 23(4); 2025 > Article
Review
IBD Elderly-onset inflammatory bowel disease in Asia: clinical characteristics and therapeutic strategies
Jiyoung Yoonorcid, Daein Kimorcid, You Sun Kimorcid
Intestinal Research 2025;23(4):430-442.
DOI: https://doi.org/10.5217/ir.2025.00221
Published online: October 28, 2025

Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea

Correspondence to You Sun Kim, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 150 Seongan-ro, Gangdong-gu, Seoul 05355, Korea. E-mail: yousunk69@korea.com
• Received: September 11, 2025   • Revised: September 23, 2025   • Accepted: September 24, 2025

© 2025 Korean Association for the Study of Intestinal Diseases.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

prev next
  • 655 Views
  • 22 Download
Full Article

Download PDF Download PDF

  • The incidence and prevalence of elderly-onset inflammatory bowel disease (EO-IBD) are increasing worldwide. The rising incidence of EO-IBD in Asia is driven by rapid industrialization and an aging population. Older patients often have multiple comorbidities and polypharmacy, which make diagnosis and management of the disease more challenging. Additionally, Asian patients with EO-IBD exhibit unique clinical characteristics, including frequent ileal involvement. Differences in phenotype between patients with EO-IBD in Western and Asian countries may explain subsequent disparities in the natural history of these patients. Although EO-IBD often manifests with a mild clinical course at diagnosis, it poses distinct diagnostic and therapeutic challenges. Understanding these characteristics is essential for optimizing patient care and for optimizing patient outcomes. In this review, we explore the epidemiology, disease burden, and clinical characteristics of EO-IBD in Asia, as well as the therapeutic approaches for treating the disease.
  • Keywords: Aged; Asia; Crohn disease; Epidemiology; Ulcerative colitis
Inflammatory bowel disease (IBD) is a chronic, progressive, and idiopathic inflammatory disorder of the gastrointestinal tract that requires lifelong treatment [1]. The incidence of IBD, including Crohn’s disease (CD) and ulcerative colitis (UC), has been increasing worldwide, including in Asia [2-8]. The sharp increase in the incidence of IBD in Asia is considered to be largely due to environmental changes, including industrialization, westernized diets, and the resulting changes in the microbiota [9-12]. Although, IBD is most often diagnosed in young adults, its diagnosis has been increasing in the older population. Older patients with IBD can be categorized into 2 groups: those newly diagnosed with IBD at an advanced age, and those diagnosed at a younger age who continue to experience the chronic effects of IBD. The aging population has emerged as a worldwide concern driven by advances in diagnosis and treatment. Notably, Asian countries, including Korea and Japan, are experiencing an increase in super-elderly populations. Elderly-onset IBD (EO-IBD) or older-onset IBD is characterized as IBD that is newly diagnosed in patients aged 60 years or older, although some studies, including the Japanese nationwide registry, have used ≥65 years [13-15]. Current estimates suggest that approximately 10% to 15% of the IBD population is classified as EO-IBD [13,16,17]. These numbers are expected to continue increasing with the aging population.
Although data are lacking, the incidence and prevalence of EO-IBD in Asian countries are projected to increase in tandem with the aging population. Consequently, EO-IBD has emerged as an important clinical condition in this region [15,18-23]. The diagnosis of EO-IBD poses a significant challenge, necessitating differential diagnosis from numerous other diseases. Furthermore, patients with EO-IBD may manifest clinical symptoms and respond differently to treatment compared with those with younger-onset IBD. A notable distinction has been observed in the demographic and phenotypic characteristics of Asian patients when compared with those from Western countries [7,24,25].
Therefore, we aimed to examine the epidemiology, clinical characteristics, diagnostic challenges, and therapeutic considerations of Asian patients with EO-IBD because understanding the unique characteristics of this distinct disease population will be crucial for clinicians in this region.
Traditionally, IBD peaks in early adulthood; however, a second peak of onset has been increasingly recognized in the older population. The incidence of EO-IBD varies among Western countries. The Danish National Patient Registry (1995–2012) reported that 21.0% of patients with UC and 17.0% of patients with CD were diagnosed after 60 years of age [26]. However, in a French population-based cohort (1988–2006), only 9.0% of patients were diagnosed with EO-IBD (11.0% with UC and 5.0% with CD) [27]. Similar results were reported in Olmstead County, Minnesota, with 12.0% diagnosed with UC and 6.0% with CD [28,29]. Overall, the incidence of EO-UC is higher than that of EO-CD. This phenomenon corresponds with data indicating that the age of onset for patients with UC exhibits a second peak after 60 years of age [30]. A study that analyzed the burden of IBD using data from the Global Burden of Disease Study 2021 [31] demonstrated that the overall incidence rate remained stable from 2000 to 2021. However, the incidence of EO-IBD has increased, accounting for 11.0% of total cases in 2021 [17]. The proportion of EO-IBD cases is highest in the Americas (14.4%) and in countries with a high sociodemographic index (14.5%), whereas it is only 5.7% in countries with a low sociodemographic index.
The prevalence of EO-IBD has also been reported in Asia (Table 1) [8,15,18-22,32-36]. However, the rate was significantly lower than that observed in Western countries. In the Korean prospective CONNECT study, conducted between January 2009 and September 2019, 1,175 patients were diagnosed with CD [37]. Of these, only 26 (2.2%) were classified as having EO-CD [18]. A large hospital-based study in Korea reported that 29 of 2,989 patients with CD had EO-CD (1.0%) [19]. Conversely, EO-UC has a much higher incidence in Korea. The frequency of EO-UC markedly increased from 3.9% (1977–1999) to 9.7% (2008–2014) (P<0.001) [32]. Additionally, a Songpa-Kangdong population-based cohort study (1986–2015) identified 99 patients with EO-UC (10.3%) [22].
The Japanese nationwide IBD registry revealed that 9.9% of patients were diagnosed with EO-UC (aged ≥65 years) between 2004 and 2009 [15]. Another Japanese study reported that the ratio of patients with EO-UC (aged ≥60 years) increased from 1.6% of those diagnosed before 2000 to 13.9% of those diagnosed after 2001 [33].
Data from China highlight regional heterogeneity. A retrospective, single-center study from China (2014–2021) demonstrated that 23.4% (184/787) of the patients diagnosed with IBD were >60 years of age [34]. However, it is uncertain whether these patients met the diagnostic criteria for EO-IBD or were older patients with IBD at a younger age.
Another Chinese cohort study (1998–2020) revealed that among 1,609 individuals diagnosed with IBD, 8.0% (n=129) were classified as having EO-IBD, with 99 cases of UC and 30 of CD [36]. Of this patient population, 17.1% had a long-term history of smoking (>35 years) [35].
A cross-sectional retrospective analysis at 2 centers in India revealed that 4.7% of the patients had EO-IBD; of these, 69.4% had UC and 30.6% had CD [21]. A retrospective population-based study from Taiwan (2016–2020), including 2,595 newly registered patients with IBD, determined that 22.9% of the patients with UC (392/1,715) and 18.9% of those with CD (167/880) were diagnosed with EO-IBD [8]. The authors suggested that with the aging population, the healthcare system may have difficulty managing EO-IBD in patients with age-related comorbidities [8].
The Asia-Pacific Crohn’s and Colitis Epidemiology Study (including 9 countries from the Asia-Pacific region) reported that the incidences of EO-UC and EO-CD were approximately 0.8/100,000 and 0.3/100,000 population, respectively [38].
The number of patients with EO-UC in Hong Kong increased from 0.1/100,000 in 1991 to 1.3/100,000 in 2010 [36]. The proportion of newly diagnosed patients with EO-UC has shown a marked and statistically significant increase over the past two decades, from 3.0% before 1990 to 21.6% after 2010. In addition, a recent study reported that 270 (11.2%) patients in the Hong Kong IBD registry (1981–2016) had EO-IBD. Compared with adult-onset IBD, patients with EO-IBD had a higher UC-to-CD ratio (3.82:1 vs. 1.39:1) [20].
In summary, the incidence of EO-IBD in Asia has trended upward, although this trend varies across different countries and remains lower than that in Western countries. EO-UC is more prevalent than EO-CD in Asia as well as in Western countries.
Several studies have indicated that a greater proportion of Asian patients with EO-IBD are current or former smokers [20,32,33,35]. In a French cohort study, EO-IBD patients had a lower family history (3.0%) than non-EO-IBD patients (7.0%) [27]. Similarly, Asian EO-IBD patients are less likely to have a family history of (1.9%–4.0%) [20,32]. These findings suggest that patients with EO-IBD are influenced more by environmental factors than genetic factors.
EO-IBD is consistently associated with an increased risk of complications. The risk of malignancy is a major concern in patients with EO-IBD. Previous studies in Taiwan and Hong Kong demonstrated that the risk of non-colorectal malignancies was substantially increased in Asian patients with IBD [39,40]. A large Chinese cohort also reported a nearly 3-fold higher overall cancer incidence in EO-IBD than in adult-onset disease, with colorectal, urinary tract, and hematologic malignancies being the most frequent (26.9 vs. 9.5 per 1,000 person-years, respectively; relative risk [RR], 2.83), patients with EO-IBD also had a shorter interval from IBD diagnosis to cancer development and higher tumor-related mortality than those with adult-onset IBD [35]. In contrast, findings from Western populations generally indicate that the overall cancer risk in older patients with IBD does not significantly differ from that of the background population [41,42]. In the French EPIMAD registry (n=844 patients with EO-IBD), the overall cancer risk was not increased in patients with EO-IBD (standardized incidence ratio [SIR], 0.97; 95% confidence interval [CI], 0.80–1.18), and the risk of colorectal cancer was not increased in patients with either UC or CD [43]. A Danish nationwide cohort reported an elevated cancer risk in patients with CD (SIR, 1.55; 95% CI, 1.29–1.84), but not in those with UC (SIR, 1.12; 95% CI, 0.97–1.28) [44]. Notably, Western studies have consistently demonstrated a higher risk of hematologic malignancies, particularly lymphoproliferative and myeloproliferative disorders [41]. However, an increased risk of colorectal cancer remains controversial [20,45]. This discrepancy likely reflects differences in genetic susceptibility, cancer surveillance practices, environmental exposures, and therapeutic strategies between regions.
Across Asia, EO-IBD is consistently associated with greater healthcare utilization. Korean data demonstrated higher UC-related and all-cause mortality rates in patients with EO-UC than in younger patients with UC (3.5% vs. 0.6% and 12.4% vs. 1.8%, respectively) [32]. In Hong Kong, patients with EO-IBD had higher rates of infection-related hospitalization (odds ratio [OR], 1.87; 95% CI, 1.47–2.38; P<0.001), higher rates of IBD-related hospitalization (OR, 1.09; 95% CI, 1.04–1.15; P=0.001), and longer hospital stays (OR, 1.004; 95% CI, 1.001–1.007; P=0.007) than those with adult-onset IBD [20]. Korean and Japanese studies have demonstrated higher corticosteroid use, greater hospitalization needs, and increased surgical interventions in patients with EO-UC [15,32]. Furthermore, older patients are at a higher risk of opportunistic infections [15,32], including Pneumocystis jirovecii pneumonia, tuberculosis reactivation, and herpes zoster, owing to immunosenescence and polypharmacy. Together, these findings underscore the heavy clinical and healthcare burden of EO-IBD.
The diagnosis of IBD in older populations presenting with diarrhea, bloody stools, or abdominal pain, can be challenging because IBD is not often considered a likely cause of these symptoms. Many other differential diagnoses are more prevalent than IBD in this age group, including colorectal cancer, diverticular disease, ischemic colitis, and other types of infectious colitis [13]. Consequently, the rate of misdiagnosis at presentation is higher in the older population (60.0%) than in those with younger-onset IBD (15.0%) [46]. Moreover, Kim et al. [18] reported that 34.6% of Korean patients with EO-CD had been prescribed anti-tuberculosis medication prior to their diagnosis of CD, which was significantly higher than that in the late adult-onset group (P<0.001), suggesting a higher likelihood of initial misdiagnosis.
1. Disease Behavior and Location
Patients with EO-IBD typically exhibit distinct characteristics in terms of disease location, extent, and phenotype compared with those with younger IBD (Fig. 1). A systematic review and meta-analysis of 43 studies revealed that the most common disease location in EO-CD was L2 (colon, 44.0% of patients) followed by L1 (ileum, 32.0%) and L3 (ileocolon, 26.0%), respectively [47]. The majority of patients with EO-CD had inflammatory disease behavior (68.0%; 95% CI, 61.0–74.0) [47]. Perianal involvement at diagnosis was infrequent, occurring in 9.0% to 12.0% of patients [47,48]. Other Western studies have reported that left-sided colitis is more prevalent in patients with EO-UC [27,49,50]. In patients with EO-CD, colonic disease and inflammatory disease behavior are more prevalent, whereas penetrating and perianal diseases are less common [27,49,51].
Patients with EO-IBD in Asian countries vary in their disease location, extent, and phenotype. Of the patients with EO-CD in the Korean prospective CONNECT study, more than half exhibited an ileal location (69.2%), which is considerably different from that observed in Western populations [18]. Another Korean study (58.6%) [19] and an Indian study (45.6%) [21] demonstrated similar results with ileal location being more prevalent in patients with EO-CD. Inflammatory disease behavior was most common in Korea (76.9%) [18], Hong Kong (64.3%) [20], and India (63.2%) [21]. A significantly lower proportion of patients with EO-CD had perianal involvement in Korea (11.5%) [18], Hong Kong (5.4%) [20], and India (5.3%) [21] compared with younger patients, who showed rates similar to those in Western populations [18].
The extent of disease at diagnosis in Korean patients with EO-UC was similar to that of younger patients, with nearly half of the patients having proctitis (45.1%) [32]. Data from Hong Kong demonstrated that patients with EO-UC were more likely to present with proctitis (37.4%), followed by left-sided (31.8%), and extensive (30.8%) colitis [20]. In India, data indicate that left-sided colitis is the most common form of EO-UC (59.7%) [21].
In summary, Asian patients with EO-CD are more likely to have ileal involvement, whereas Western patients are more likely to have colonic involvement. However, the prevalence of perianal involvement and inflammatory disease behavior is similar between Asian and Western populations. Patients with EO-UC in Asia are more likely to have proctitis than those in the West, where left-sided colitis is more common; however, this varies by country.
2. Comorbidities and Disease Course
EO-IBD is commonly assumed to have a favorable prognosis; however, the available evidence remains inconclusive. Some studies have suggested that patients with EO-IBD have a poor prognosis, as evidenced by a higher rate of hospitalization and colectomy [32,52]. However, other studies suggest that the prognosis is comparable to that of the young-onset IBD population, evidenced by similar or reduced surgery rates and a reduced probability of disease extension and complicated behavior [18,22,27,53,54].
Age is an important factor that influences disease course. Additionally, aging may be associated with a relative immunosenescence resulting from a decline in both innate and adaptive immunity [55]. Moreover, patients with EO-IBD frequently have or develop comorbidities such as cardiovascular disease, diabetes, renal disease, and malignancies [20,35], and the use of multiple medications for various ailments can augment the risk of drug–drug interactions.
Regarding Asian EO-IBD patients, the Korean prospective CONNECT study revealed that Crohn’s Disease Activity Index at EO-CD diagnosis (124.9±101.9) was significantly lower than that of the late adult-onset group (189.6 ±128.6) (P=0.023). This finding suggests that patients with EO-CD exhibit reduced clinical disease activity at the time of diagnosis. A study in India found that the majority of patients with EO-IBD had moderate disease severity (CD, 64.9%; UC, 69.7%) at the time of diagnosis [21].
Although the disease may appear milder at onset, patients with EO-IBD face higher rates of complications, including infections and hospitalization. A study conducted in Hong Kong reported that patients with EO-UC had higher mortality rates than those with younger-onset disease (7.0% vs. 1.0%; P<0.001); similarly, the mortality rates of UC-related complications were 1.9% and 0.2%, respectively (P=0.017) [36].
However, a Songpa-Kangdong population-based cohort study of Korean patients with EO-UC showed that the disease course in terms of proximal disease extension, hospitalization, and colectomy was similar to that of patients with younger-onset disease [22]. In addition, the Korean prospective CONNECT study revealed the cumulative probability of bowel resection in the EO-CD group tended to be lower than that in the late adult-onset group (P=0.067) [18]. Moreover, the Korean retrospective CONNECT study reported no significant difference in the cumulative probability of bowel resection across age groups. Taken together, these findings suggest that the surgical risk in EO-CD is generally comparable to, or even slightly lower than, that in younger-onset disease [54].
An American retrospective analysis evaluated treatment- and disease-related complications in 2 distinct older IBD populations: patients aged >60 years with adult-onset IBD and those with EO-IBD. The analysis revealed that the risk of disease-related complications did not significantly differ between the 2 groups (adjusted hazard ratio [HR], 0.85; 95% CI, 0.58–1.25), suggesting that the disease courses of these 2 populations were comparable. However, the adult-onset IBD group exhibited a reduced risk of treatment-related complications, including malignancy, mortality, and serious infections (adjusted HR, 0.58; 95% CI, 0.39–0.87) [46]. Therefore, clinicians should balance the anticipated disease course and the risk of serious treatment-associated adverse events (AEs) when treating patients with EO-IBD [46,56].
Despite the limitations of the available data, EO-IBD is likely not milder than younger-onset IBD. Patients and physicians should be aware of the possibility of aggressive disease behaviors even later in life; appropriate treatment decisions should be made based on the potential implications of active disease on associated comorbidities, and disease complications [57]. A recent systematic review (9 studies, 14,765 patients with EO-IBD) compared the natural history and outcomes of EO-IBD to adult-onset IBD based on population-based cohort studies [58]. The cumulative 5-year risk of surgery in patients with EO-CD was 22.6% (95% CI, 18.7–27.2), similar to that of patients with adult-onset CD (RR, 1.04; 95% CI, 0.80–1.34). The cumulative 5-year risk of surgery in patients with EO-UC was 7.8% (95% CI, 5.0%–12.0%), similar to that of patients with adult-onset UC (RR, 1.29; 95% CI, 0.79–2.11). Thus, this study found similar risks of surgery, hospitalization and corticosteroid exposure between these groups, suggesting a similar disease course [58]. A comparison of clinical characteristics and disease burden of EO-IBD between Asian and Western populations is presented in Table 2.
Treating patients with EO-IBD can be challenging. The older population may have several underlying comorbidities, as well as important geriatric features such as frailty and polypharmacy. Polypharmacy is common, with an average of 7 drugs per patient with EO-CD [59]. Therefore, patients with EO-IBD are often undertreated because of safety concerns regarding advanced therapy [60].
1. General Consideration
Although many clinical studies on biologics and novel small-molecule agents for the treatment of IBD are underway, older patients are often excluded from clinical trials. Patients with EO-IBD are usually treated conservatively with consideration of frequent comorbidities, which may increase the risk of treatment-related complications [46,60]. The milder disease course of EO-IBD and the reluctance of physicians to use immunomodulators or biologics may also explain the undertreatment of patients with EO-IBD. An international survey study (424 respondents from 41 countries) demonstrated that physicians avoid the use of thiopurines and anti-tumor necrosis factor-alpha (anti-TNF) agents in older patients with IBD because of concerns regarding lymphoma (94.0%) and opportunistic infections (78.3%) [61].
Therefore, when selecting medication for patients with EO-IBD, it is crucial to consider the effectiveness of the medication and its potential side effects. These side effects may include infections, polypharmacy, drug–drug interactions, and malignancy. Additionally, patients with EO-IBD may have cognitive problems such as dementia, depression, and other neuropsychiatric issues. The nutritional status of patients with EO-IBD is also important for preventing a poor clinical course [62]. Consequently, a multidisciplinary approach is necessary to ensure comprehensive and coordinated care.
2. Infection and Vaccination
Patients with EO-IBD are vulnerable to therapy-related AEs, particularly infections arising from systemic immunosuppression. The annual incidence of serious infections in patients aged ≥65 years who are exposed to immunomodulators or biologics is approximately 5.0% [63]. Vaccination against pneumococcal and influenza infections is strongly recommended for patients with EO-IBD [13,64]. Patients who are >65 years of age and/or immunosuppressed should receive at least 1 dose of pneumococcal vaccine, with revaccination after 5 years; the influenza vaccine should be administered annually [65]. Vaccination against herpes zoster is also recommended, in particular, who would be treated with small molecules such as anti-JAK agents [66].
Furthermore, Asian countries have several unique infection risks, including tuberculosis, cytomegalovirus, and herpes zoster [67]. According to a study conducted in Hong Kong, patients with EO-IBD had higher risks of cytomegalovirus colitis (OR, 3.07; 95% CI, 1.92–4.89; P<0.001), while the risk of herpes zoster was higher numerically (OR, 2.42; 95% CI, 1.22–4.80) but was not statistically significant (P=0.120) [20].
3. Conventional Treatment
The efficacy of 5-aminosalicylic acid (5-ASA), corticosteroids, and immunomodulators do not differ between EO-IBD and younger-onset IBD [13,68].

1) 5-Aminosalicylic Acid

5-ASA is effective in inducing and maintaining remission in patients with mild-to-moderate UC. Interestingly, Target-IBD cohort study demonstrated that older patients with IBD are significantly more likely to receive 5-ASA monotherapy as a treatment for both CD and UC [69].
5-ASA is relatively safe for patients with EO-IBD; however, these patients have a potentially increased risk of nephrotoxicity because of the slower elimination of 5-ASA. Therefore, caution should be exercised when using 5-ASA in patients with EO-IBD and preexisting renal dysfunction, and careful monitoring is warranted [70]. A Korean study showed that 100% of patients with EO-CD were prescribed 5-ASA [18] and a Hong Kong study found that 71.2% of patients with EO-IBD were on 5-ASA at diagnosis [20]. An Indian study demonstrated that 82.6% of the patients with EO-CD and 100% of those with EO-UC were taking 5-ASA [21].

2) Steroids

Steroids are an effective treatment for EO-IBD and are commonly used to induce remission. However, steroids can cause serious side effects, including high blood pressure, diabetes, cataracts, osteoporosis, fractures, sleep disturbances and cognitive impairment. Steroids are also associated with a high risk of serious infections in older patients. Patients with EO-IBD who were administered steroids have a 2.3-fold increased risk of infection compared with non-exposed patients (95% CI, 1.8–2.9) [71]. Nonetheless, steroids are widely used in the treatment of EO-IBD. A multicenter study demonstrated that 31.6% of older patients with IBD (>65 years of age) were prescribed corticosteroids for at least 6 months [59]. The rate of steroid use varies in Asian patients with EO-IBD. Nearly half (46.2%) of Korean patients with EO-CD received steroid treatment [18], however, only 30.3% of Korean patients with EO-UC were treated with steroids [22]. A Hong Kong study revealed that 23.8% of patients with EO-IBD received steroid treatment [20], whereas an Indian study reported that 68.4% of patients with EO-CD and 40.3% of those with EO-UC were treated with steroids [21].

3) Immunomodulators

Immunomodulators including thiopurines and methotrexate, may be indicated for patients with EO-IBD to maintain remission, especially in those with steroid dependence. However, the use of immunomodulators is associated with a higher risk of opportunistic infections and other serious adverse effects, such as a higher risk of malignancy.
Thiopurines have been shown to be equally effective in patients with EO-IBD and younger adults [68]. However, thiopurine may increase the risk of non-Hodgkin’s lymphoma, and the risk of lymphoma increases with age [56,72]. In a French cohort study, the incidence of lymphoma was significantly higher in older patients with IBD taking thiopurines compared with those ≤ 50 years of age (5.41 vs. 0.37 per 1,000 person-years) [72]. In addition, thiopurine use is strongly associated with infections and other AEs in older patients with IBD. When comparing thiopurine-related AEs in patients who started thiopurines at >60 years of age with those that started at 18–50 years of age, a significantly higher risk of infection was noted in the older group (3.6% vs. 2.0%; P<0.001) [73]. Moreover, patients starting thiopurines at >60 years of age had higher rates of all types of myelotoxicity, digestive intolerance, and hepatotoxicity, leading to a higher rate of discontinuation when compared with the younger group (67.2% vs. 63.1%; P<0.001) [73]. Indeed, physicians are reluctant to use immunomodulators in older patients, and a retrospective study of 393 patients with EO-IBD (aged >65 years) showed that only 5.6% were on thiopurines and 1.0% were on methotrexate [59].
A Korean study also reported that immunomodulators were used less frequently in the EO-CD group (48.1%) than in the non-EO-CD group (87.0%; P<0.001) [19]. Additionally, an Indian study reported significantly lower rates of thiopurine use in EO-UC (10.1%) and EO-CD (10.5%) than in non-EO-UC (39.9%; P<0.001) and non-EO-CD (72.1%; P<0.001) [21].

4) Advanced Therapy

In clinical practice, biologics and small molecules are underutilized in the EO-IBD population. Increased toxicity and decreased efficacy are major concerns in the older population. Several studies have shown that the use of immunomodulators or biologics is lower in patients with EO-IBD. Among the 841 patients with EO-IBD in a French cohort, only 7.0% were treated with anti-TNF agents and 16.0% with immunomodulators [27]. The Target-IBD cohort study evaluated the medication utilization pattern and revealed that older patients with IBD were less frequently prescribed anti-TNF agents than younger patients [69].
In Asian countries, Kim et al. [18] reported that patients with EO-CD were significantly less likely to use anti-TNF agents than younger patients (P=0.047). A Hong Kong study presented similar results, demonstrating that patients with EO-IBD had a significantly lower cumulative use of biologics (P=0.040) [20]. In contrast, a Korean population-based study found that the cumulative risks of anti-TNF use were not different between the EO-UC and non-EO-UC groups (P=0.095) [22].
No differences in the efficacies of biologics have been reported for EO-IBD [13]. Indeed, the data are conflicting regarding the efficacy of biologics in the older population. A multicenter observational study comparing the efficacy of anti-TNF agents between patients with EO-IBD and older patients with non-EO-IBD found that, after 52 weeks of anti-TNF treatment, clinical and steroid-free remission rates were significantly lower in those with EO-IBD (37.7% vs. 60.8%, P=0.001 and 35.9% vs. 57.8%, P=0.003, respectively) [74]. Multivariate analysis revealed that elderly onset was a significant factor for both clinical remission (OR, 0.49; 95% CI, 0.25–0.96) and steroid-free remission (OR, 0.51; 95% CI, 0.26–0.99). However, in a meta-analysis of 4 randomized controlled trials of patients with UC (n=231, aged ≥ 60 years), the effect of anti-TNF agents was similar for induction of remission (OR, 1.05; 95% CI, 0.33–3.39) and maintenance of remission (OR, 0.49; 95% CI, 0.18–1.33) between older and younger patient groups [75].
Several studies on the safety of biologics including anti-TNF agents in older adults have been published. In a meta-analysis of autoimmune diseases treated with biologics (4,719 biologic users aged ≥60 years; 13,305 biologics users aged <60 years; 3,961 biologics non-users aged ≥60 years), the rates of all infections were higher in older biologic users than in younger biologics users (13.0% vs. 6.0%; OR, 2.28; 95% CI, 1.57–3.31); infection rates were also higher in older biologic users than in biologic non-users (OR, 3.60; 95% CI, 1.62–8.01) [76]. Another study including a total of 895 patients with IBD (age at anti-TNF initiation: <40 years [n=546, 61.0%], 40–59 years [n=268, 29.9%], and ≥ 60 years [n=81, 9.1%]) determined that treatment failure rates were higher in the older group (subhazard rate for age ≥60 years, 1.46). The subhazard rate in the older group (≥60 years) was 1.52 for discontinuation because of AEs and 1.11 for lack of effectiveness [77].
In summary, these findings suggest that anti-TNF agents have similar or slightly reduced effects in older patients with IBD compared with younger adults. However, older adults are at a higher risk of AEs, including infections, owing to age-related factors. Therefore, given their effectiveness, anti-TNF agents should be considered when necessary, despite the risk of infection.
Vedolizumab is the preferred first-line agent for treating older patients with IBD and steroid-dependent moderate-to-severe UC [61]. Vedolizumab is considered relatively safe biologics, because it is gut-specific. A post hoc analysis of GEMINI trials showed that safety profiles of vedolizumab and placebo were similar in all age groups, even in patients aged ≥ 55 years [78]. Regarding the efficacy of vedolizumab, a real-world retrospective cohort study revealed the similar efficacy of vedolizumab for the younger and elderly groups in terms of durability during the 6- to 12-month period after initiation (46.8% vs. 40.1%; P=0.237) [79]. Therefore, vedolizumab can be considered a safe option in EO-IBD patients.
Data on the use of ustekinumab in older patients with IBD is limited. Regarding efficacy, a retrospective real-world study showed that nearly 90% patients in older and younger CD patients experienced clinical response; however, the older group was less likely to achieve complete clinical remission (28.2% vs. 52.6%; P=0.010) [80]. In the UNITI and UNIFI studies, the risk of serious AEs or infections was not increased at any age [81,82]. Thus, ustekinumab may be a suitable alternative in patients with EO-IBD who have an increased risk of infection.
Tofacitinib is an effective agent for treating moderately to severely active UC. However, AEs including reactivation of herpes zoster and venous thromboembolism, have been reported, and increasing age seems to be a risk factor. Therefore, the use of tofacitinib in patients with EO-IBD should be carefully considered [83].
The aging population in Asia has led to an increase in the prevalence of EO-IBD, and this trend is anticipated to persist. The prevalence of ileal involvement is notable among Asian patients with EO-CD, a phenomenon that contrasts with Western patients, where colonic involvement is more common. Furthermore, differentiating patients with EO-CD from those with tuberculous enterocolitis is imperative in Asia. Although EO-IBD often manifests with a milder clinical course at diagnosis, it poses distinct diagnostic and therapeutic challenges. Optimizing care will require the integration of age-specific risk assessments, comorbidity management, and the cautious yet effective use of biologics and small molecules. Phenotypic differences, such as disease location, between Western and Asian populations may explain the subsequent disparities in the natural history of patients with EO-IBD. Consequently, treatment policies for Asian patients with EO-IBD may require adaptation from those established in Western countries. Therefore, real-world efficacy and safety data on biologics and small molecules in Asian patients with EO-IBD are essential. Furthermore, the development of evidence-based guidelines for patients with EO-IBD in Asia requires regional collaboration.

Funding Source

This work was supported by a grant (No. 2025-02) from the Kangdong Sacred Heart Hospital Fund.

Conflict of Interest

Kim YS is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.

Data Availability Statement

Data sharing is not applicable as no new data were created or analyzed in this study.

Author Contributions

Conceptualization: Kim YS. Data curation: Kim YS. Data interpretation: Yoon J, Kim D. Formal analysis: Yoon J, Kim D, Kim YS. Supervision: Kim YS. Writing - orginal draft: Yoon J, Kim YS. Writing - review & editing: all authors. Approval of final manuscript: all authors.

Fig. 1.
Specific characteristics and therapeutic strategies of elderly-onset inflammatory bowel disease in Asia [14].
ir-2025-00221f1.jpg
Table 1
Epidemiology and Disease Burden of EO-IBD in Asia
Country Data source Study period No. of patients Elderly-onset group The age at diagnosis (yr) Male sex
Korea [18,19] The Korean prospective connect cohort study (CD) 2009.1–2019.9 1,175 26 (2.2) 67.5±6.7 14 (53.8)
A large hospital-based cohort (CD) 1989.6–2016.12 2,989 29 (1.0) 64.5 (62.3–69.6) 11 (37.9)
Korea [22,32] A large hospital-based cohort (UC) 1989.6–2016.12 3,060 226 (7.4) 65.9 (62.9–68.7) 132 (58.4)
The population-based cohort (The Songpa-Kangdong, UC) 1986–2015 965 99 (10.3) 66 (62–68) 65 (65.7)
Japan [15,33] The national database (UC) 2004–2009 28,179 2,778 (9.9) 72.3 (65–92)a 1,692 (60.9)
A hospital-based cohort (UC) 2006.4–2010.3 343 32 (9.3) NAb NA
China [34,35] A hospital-based cohort (CD and UC) 2014.1–2021.12 787 184 (23.4)c NAb 82 (44.5)d
A hospital-based cohort (CD and UC) 1998.1–2020.12 1,609 129 (8.0) 65.2±5.6 84 (65.1)
India [21] 2 Tertiary IBD centers (CD and UC) 1991.1–2020.12 3,992 186 (4.7) 65.3±15.7e 116 (62.3)
2016.1–2020.12 65.9±7.6f
Taiwan [8] The NHI database (CD and UC) 2016–2020 2,595 559 (21.5) NAb NAg
Hong Kong [20,36] The Hong Kong IBD registry (CD and UC) 1981–2016 2,413 270 (11.2) 68.1±6.7 156 (57.8)
The Hong Kong IBD registry (UC) 1981–2013 1,225 157 (12.8) NAb 88 (56.1)

Values are presented as number (%), mean±SD, or number (%).

a Median (range).

b Patients aged 60 years and older were included.

c It is uncertain whether these patients represent those who later transition to old age (non-elderly onset) or those diagnosed15 at older age.

d This value is an estimate derived from the figure in the main text.

e This value corresponds to CD.

F This value corresponds to UC.

g The male-to-female ratio in the study sample was 1.83:1 for CD and 1.69:1 for UC.

EO-IBD, elderly onset-inflammatory bowel disease; CD, Crohn’s disease; UC, ulcerative colitis; NHI, National Health Insurance; NA, not available; SD, standard deviation; IQR, interquartile range.

Table 2
Comparison of Clinical Characteristics of EO-IBD between Asian and Western Countries
Characteristics Asia West
CD
 Common disease location Ileum [18,19,21] Colon [47,49]
 Disease behavior Inflammatory [18,20,21] Inflammatory [27,47,49]
 Perianal involvement Low [18,20,21] (Korea 11.5%, Hong Kong 5.4%, India 5.3%) Relatively low [46,47] (9%–12%)
 Disease course Similar or lower risk of surgery [18,54] Mixed findings across cohorts [58]
UC
 Common disease extent Proctitis [20,32] (Korea 45.1%, Hong Kong 37.4%) Left-sided colitis [27,49,50]
 Disease course Similar or higher risk of surgery compared with younger onset [15,22,32] Similar or higher risk of surgery compared with younger onset [27,53,58]
Disease burden of EO-IBD
 Malignancy risk Higher overall malignancy risk [35,39,40] (colorectal, urinary tract, hematologic malignancy) Higher hematologic malignancy risk; overall cancer risk often not increased vs. general population; CRC risk controversioal [41–43]
 Mortality EO-UC higher mortality vs. younger UC [33,38] (Hong Kong: UC-related 7.0% vs. 1.0%; all-cause 1.9% vs. 0.2%; Korea: UC-related 3.5% vs. 0.6%; all-cause 12.4% vs. 1.8%) Generally comparable to background population [41,42,46]
 Hospitalization Higher hospitalization and longer stays [15,20,32]; Some cohorts show similar to younger onset UC (Korea) [21] Mixed findings across cohorts (similar or higher than younger onset) [27,46,52,53,58]
 Infections Higher infection risks [15,32] (e.g., TB, CMV, herpes zoster) Higher infection risks [46]

EO-IBD, elderly onset-inflammatory bowel disease; CD, Crohn’s disease; UC, ulcerative colitis; CRC, colorectal cancer; TB, tuberculosis; CMV, cytomegalovirus.

  • 1. Kaser A, Zeissig S, Blumberg RS. Inflammatory bowel disease. Annu Rev Immunol 2010;28:573–621.ArticlePubMedPMC
  • 2. Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 2021;18:56–66.ArticlePubMedPMCPDF
  • 3. Park SH. Update on the epidemiology of inflammatory bowel disease in Asia: where are we now? Intest Res 2022;20:159–164.ArticlePubMedPMCPDF
  • 4. Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet 2017;390:2769–2778.ArticlePubMed
  • 5. Sood A, Kaur K, Mahajan R, et al. Colitis and Crohn’s Foundation (India): a first nationwide inflammatory bowel disease registry. Intest Res 2021;19:206–216.ArticlePubMedPMCPDF
  • 6. Hracs L, Windsor JW, Gorospe J, et al. Global evolution of inflammatory bowel disease across epidemiologic stages. Nature 2025;642:458–466.PubMedPMC
  • 7. Banerjee R, Pal P, Hilmi I, et al. Emerging inflammatory bowel disease demographics, phenotype, and treatment in South Asia, South-East Asia, and Middle East: preliminary findings from the Inflammatory Bowel Disease-Emerging Nations’ Consortium. J Gastroenterol Hepatol 2022;37:1004–1015.ArticlePubMedPDF
  • 8. Kuo CJ, Lin CY, Le PH, et al. Temporal trends of inflammatory bowel diseases in Taiwan from 2016 to 2020: a population-based study. Dig Dis Sci 2024;69:3172–3179.ArticlePubMedPDF
  • 9. Mahadevan U, Silverberg MS. Inflammatory bowel disease-gastroenterology diamond jubilee review. Gastroenterology 2018;154:1555–1558.ArticlePubMed
  • 10. Chang JT. Pathophysiology of inflammatory bowel diseases. N Engl J Med 2020;383:2652–2664.ArticlePubMed
  • 11. Lo CH, Khandpur N, Rossato SL, et al. Ultra-processed foods and risk of Crohn’s disease and ulcerative colitis: a prospective cohort study. Clin Gastroenterol Hepatol 2022;20:e1323–e1337.ArticlePubMedPMC
  • 12. Pandey H, Jain D, Tang DWT, Wong SH, Lal D. Gut microbiota in pathophysiology, diagnosis, and therapeutics of inflammatory bowel disease. Intest Res 2024;22:15–43.ArticlePubMedPMCPDF
  • 13. Sturm A, Maaser C, Mendall M, et al. European Crohn’s and Colitis Organisation topical review on IBD in the elderly. J Crohns Colitis 2017;11:263–273.PubMed
  • 14. Sousa P, Bertani L, Rodrigues C. Management of inflammatory bowel disease in the elderly: a review. Dig Liver Dis 2023;55:1001–1009.ArticlePubMed
  • 15. Komoto S, Higashiyama M, Watanabe C, et al. Clinical differences between elderly-onset ulcerative colitis and non-elderly-onset ulcerative colitis: a nationwide survey data in Japan. J Gastroenterol Hepatol 2018;33:1839–1843.ArticlePubMedPDF
  • 16. Axenfeld E, Katz S, Faye AS. Management considerations for the older adult with inflammatory bowel disease. Gastroenterol Hepatol (N Y) 2023;19:592–599.PubMedPMC
  • 17. Danpanichkul P, Duangsonk K, Ho AHY, et al. Disproportionately increasing incidence of inflammatory bowel disease in female patients and the elderly: an update analysis from the Global Burden of Disease Study 2021. Am J Gastroenterol 2025;120:675–680.ArticlePubMed
  • 18. Kim YS, Na MJ, Ye BD, Cheon JH, Im JP, Kim JS. Clinical characteristics of Korean patients with elderly-onset Crohn’s disease: results from the Prospective CONNECT Study. Gut Liver 2022;16:995–1000.ArticlePubMedPMC
  • 19. Song EM, Kim N, Lee SH, et al. Clinical characteristics and long-term prognosis of elderly-onset Crohn’s disease. Scand J Gastroenterol 2018;53:417–425.ArticlePubMed
  • 20. Mak JW, Lok Tung Ho C, Wong K, et al. Epidemiology and natural history of elderly-onset inflammatory bowel disease: results from a territory-wide Hong Kong IBD Registry. J Crohns Colitis 2021;15:401–408.ArticlePubMedPDF
  • 21. Gupta YK, Singh A, Narang V, et al. Clinical spectrum of elderly-onset inflammatory bowel disease in India. Intest Res 2023;21:216–225.ArticlePubMedPMCPDF
  • 22. Park SH, Jeong SK, Lee JH, et al. Clinical characteristics and long-term prognosis of elderly-onset ulcerative colitis in a population-based cohort in the Songpa-Kangdong district of Seoul, Korea. Gut Liver 2021;15:742–751.ArticlePubMedPMC
  • 23. Kedia S, Limdi JK, Ahuja V. Management of inflammatory bowel disease in older persons: evolving paradigms. Intest Res 2018;16:194–208.ArticlePubMedPMCPDF
  • 24. Song EM, Yang SK. Natural history of inflammatory bowel disease: a comparison between the East and the West. Intest Res 2022;20:418–430.ArticlePubMedPMCPDF
  • 25. Kim KW, Kang HW. Regional variations in the prevalence of primary sclerosing cholangitis associated with inflammatory bowel disease. Intest Res 2023;21:413–414.ArticlePubMedPMCPDF
  • 26. Nørgård BM, Nielsen J, Fonager K, Kjeldsen J, Jacobsen BA, Qvist N. The incidence of ulcerative colitis (1995-2011) and Crohn’s disease (1995-2012): based on nationwide Danish registry data. J Crohns Colitis 2014;8:1274–1280.ArticlePubMed
  • 27. Charpentier C, Salleron J, Savoye G, et al. Natural history of elderly-onset inflammatory bowel disease: a population-based cohort study. Gut 2014;63:423–432.ArticlePubMed
  • 28. Loftus EV, Silverstein MD, Sandborn WJ, Tremaine WJ, Harmsen WS, Zinsmeister AR. Crohn’s disease in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival. Gastroenterology 1998;114:1161–1168.ArticlePubMed
  • 29. Loftus EV, Silverstein MD, Sandborn WJ, Tremaine WJ, Harmsen WS, Zinsmeister AR. Ulcerative colitis in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival. Gut 2000;46:336–343.ArticlePubMedPMC
  • 30. Loftus CG, Loftus EV, Harmsen WS, et al. Update on the incidence and prevalence of Crohn’s disease and ulcerative colitis in Olmsted County, Minnesota, 1940-2000. Inflamm Bowel Dis 2007;13:254–261.ArticlePubMed
  • 31. GBD 2021 Causes of Death Collaborators. Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2024;403:2100–2132.PubMedPMC
  • 32. Song EM, Lee HS, Park SH, et al. Clinical characteristics and long-term prognosis of elderly onset ulcerative colitis. J Gastroenterol Hepatol 2018;33:172–179.ArticlePubMedPDF
  • 33. Takahashi H, Matsui T, Hisabe T, et al. Second peak in the distribution of age at onset of ulcerative colitis in relation to smoking cessation. J Gastroenterol Hepatol 2014;29:1603–1608.ArticlePubMedPDF
  • 34. Mi L, Wang K, Yao J, et al. Clinical characteristics and treatment of middle-aged and elderly patients with IBD in Shanghai, China. Int J Gen Med 2024;17:6053–6064.ArticlePubMedPMCPDF
  • 35. Wang Z, Zhang H, Yang H, Zhang M, Qian J. The incidence rate and risk factors of malignancy in elderly-onset inflammatory bowel disease: a Chinese Cohort Study from 1998 to 2020. Front Oncol 2021;11:788980.ArticlePubMedPMC
  • 36. Shi HY, Chan FK, Leung WK, et al. Natural history of elderly-onset ulcerative colitis: results from a territory-wide inflammatory bowel disease registry. J Crohns Colitis 2016;10:176–185.PubMed
  • 37. Hong SW, Ye BD, Cheon JH, et al. Clinical features and long-term prognosis of Crohn’s disease in Korea: results from the Prospective CONNECT Study. Gut Liver 2022;16:907–920.ArticlePubMedPMC
  • 38. Ng SC, Tang W, Ching JY, et al. Incidence and phenotype of inflammatory bowel disease based on results from the Asia-Pacific Crohn’s and Colitis Epidemiology Study. Gastroenterology 2013;145:158–165.ArticlePubMed
  • 39. So J, Tang W, Leung WK, et al. Cancer risk in 2621 Chinese patients with inflammatory bowel disease: a population-based cohort study. Inflamm Bowel Dis 2017;23:2061–2068.PubMed
  • 40. Wang LH, Yang YJ, Cheng WC, Wang WM, Lin SH, Shieh CC. Higher risk for hematological malignancies in inflammatory bowel disease: a nationwide population-based study in Taiwan. Am J Gastroenterol 2016;111:1313–1319.ArticlePubMedPDF
  • 41. Cheddani H, Dauchet L, Fumery M, et al. Cancer in elderly onset inflammatory bowel disease: a population-based study. Am J Gastroenterol 2016;111:1428–1436.ArticlePubMedPDF
  • 42. Pedersen N, Duricova D, Elkjaer M, Gamborg M, Munkholm P, Jess T. Risk of extra-intestinal cancer in inflammatory bowel disease: meta-analysis of population-based cohort studies. Am J Gastroenterol 2010;105:1480–1487.ArticlePubMedPDF
  • 43. Gower-Rousseau C, Vasseur F, Fumery M, et al. Epidemiology of inflammatory bowel diseases: new insights from a French population-based registry (EPIMAD). Dig Liver Dis 2013;45:89–94.ArticlePubMed
  • 44. Jess T, Horváth-Puhó E, Fallingborg J, Rasmussen HH, Jacobsen BA. Cancer risk in inflammatory bowel disease according to patient phenotype and treatment: a Danish population-based cohort study. Am J Gastroenterol 2013;108:1869–1876.ArticlePubMedPDF
  • 45. Baars JE, Kuipers EJ, van Haastert M, Nicolaï JJ, Poen AC, van der Woude CJ. Age at diagnosis of inflammatory bowel disease influences early development of colorectal cancer in inflammatory bowel disease patients: a nationwide, long-term survey. J Gastroenterol 2012;47:1308–1322.ArticlePubMedPMC
  • 46. Rozich JJ, Luo J, Dulai PS, et al. Disease- and treatment-related complications in older patients with inflammatory bowel diseases: comparison of adult-onset vs elderly-onset disease. Inflamm Bowel Dis 2021;27:1215–1223.ArticlePubMedPMCPDF
  • 47. Ananthakrishnan AN, Shi HY, Tang W, et al. Systematic review and meta-analysis: phenotype and clinical outcomes of older-onset inflammatory bowel disease. J Crohns Colitis 2016;10:1224–1236.ArticlePubMedPMC
  • 48. Danielou M, Sarter H, Pariente B, et al. Natural history of perianal fistulising lesions in patients with elderly-onset Crohn’s disease: a population-based study. J Crohns Colitis 2020;14:501–507.PubMed
  • 49. King D, Reulen RC, Thomas T, et al. Changing patterns in the epidemiology and outcomes of inflammatory bowel disease in the United Kingdom: 2000-2018. Aliment Pharmacol Ther 2020;51:922–934.ArticlePubMedPDF
  • 50. Zammarchi I, Lanzarotto F, Cannatelli R, et al. Elderly-onset vs adult-onset ulcerative colitis: a different natural history? BMC Gastroenterol 2020;20:147.ArticlePubMedPMCPDF
  • 51. Viola A, Monterubbianesi R, Scalisi G, et al. Late-onset Crohn’s disease: a comparison of disease behaviour and therapy with younger adult patients: the Italian Group for the Study of Inflammatory Bowel Disease ‘AGED’ study. Eur J Gastroenterol Hepatol 2019;31:1361–1369.ArticlePubMed
  • 52. Mañosa M, Calafat M, de Francisco R, et al. Phenotype and natural history of elderly onset inflammatory bowel disease: a multicentre, case-control study. Aliment Pharmacol Ther 2018;47:605–614.PubMed
  • 53. Jeuring SF, van den Heuvel TR, Zeegers MP, et al. Epidemiology and long-term outcome of inflammatory bowel disease diagnosed at elderly age-an increasing distinct entity? Inflamm Bowel Dis 2016;22:1425–1434.ArticlePubMed
  • 54. Hwang SW, Kim JH, Im JP, et al. Influence of age at diagnosis on the clinical characteristics of Crohn’s disease in Korea: results from the CONNECT study. J Gastroenterol Hepatol 2017;32:1716–1722.ArticlePubMedPDF
  • 55. Cambier J. Immunosenescence: a problem of lymphopoiesis, homeostasis, microenvironment, and signaling. Immunol Rev 2005;205:5–6.ArticlePubMed
  • 56. Beaugerie L, Kirchgesner J. Balancing benefit vs risk of immunosuppressive therapy for individual patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol 2019;17:370–379.ArticlePubMed
  • 57. Ananthakrishnan AN. Precision medicine in inflammatory bowel diseases. Intest Res 2024;22:8–14.ArticlePubMedPMCPDF
  • 58. Rozich JJ, Dulai PS, Fumery M, Sandborn WJ, Singh S. Progression of elderly onset inflammatory bowel diseases: a systematic review and meta-analysis of population-based cohort studies. Clin Gastroenterol Hepatol 2020;18:2437–2447.ArticlePubMedPMC
  • 59. Juneja M, Baidoo L, Schwartz MB, et al. Geriatric inflammatory bowel disease: phenotypic presentation, treatment patterns, nutritional status, outcomes, and comorbidity. Dig Dis Sci 2012;57:2408–2415.ArticlePubMedPDF
  • 60. Lee WS, Azmi N, Ng RT, et al. Fatal infections in older patients with inflammatory bowel disease on anti-tumor necrosis factor therapy. Intest Res 2017;15:524–528.ArticlePubMedPMCPDF
  • 61. Chan W, Kariyawasam VC, Kim S, et al. Gastroenterologists’ preference and risk perception on the use of immunomodulators and biological therapies in elderly patients with ulcerative colitis: an international survey. Eur J Gastroenterol Hepatol 2020;32:976–983.ArticlePubMed
  • 62. Higashiyama M, Komoto S, Suzuki Y, et al. Relation of geriatric nutritional risk index with clinical risks in elderly-onset ulcerative colitis. J Gastroenterol Hepatol 2021;36:163–170.ArticlePubMedPDF
  • 63. Kirchgesner J, Lemaitre M, Carrat F, Zureik M, Carbonnel F, Dray-Spira R. Risk of serious and opportunistic infections associated with treatment of inflammatory bowel diseases. Gastroenterology 2018;155:337–346.ArticlePubMed
  • 64. Kucharzik T, Ellul P, Greuter T, et al. ECCO guidelines on the prevention, diagnosis, and management of infections in inflammatory bowel disease. J Crohns Colitis 2021;15:879–913.ArticlePubMedPDF
  • 65. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2014;63:822–825.PubMedPMC
  • 66. Winthrop KL, Melmed GY, Vermeire S, et al. Herpes zoster infection in patients with ulcerative colitis receiving tofacitinib. Inflamm Bowel Dis 2018;24:2258–2265.ArticlePubMedPMC
  • 67. Baek JE, Hwang SW. Diagnosis, management, and prevention of infectious complications in inflammatory bowel disease: variations among Asian countries. Intest Res 2023;21:277–279.ArticlePubMedPMCPDF
  • 68. Chaparro M, Ordás I, Cabré E, et al. Safety of thiopurine therapy in inflammatory bowel disease: long-term follow-up study of 3931 patients. Inflamm Bowel Dis 2013;19:1404–1410.PubMed
  • 69. Barnes EL, Hanson JS, Regueiro MD, et al. Older adult patients use more aminosalicylate monotherapy compared with younger patients with inflammatory bowel disease: TARGET-IBD. J Clin Gastroenterol 2022;56:529–535.PubMed
  • 70. Gisbert JP, González-Lama Y, Maté J. 5-Aminosalicylates and renal function in inflammatory bowel disease: a systematic review. Inflamm Bowel Dis 2007;13:629–638.PubMed
  • 71. Brassard P, Bitton A, Suissa A, Sinyavskaya L, Patenaude V, Suissa S. Oral corticosteroids and the risk of serious infections in patients with elderly-onset inflammatory bowel diseases. Am J Gastroenterol 2014;109:1795–1802.ArticlePubMedPDF
  • 72. Beaugerie L, Brousse N, Bouvier AM, et al. Lymphoproliferative disorders in patients receiving thiopurines for inflammatory bowel disease: a prospective observational cohort study. Lancet 2009;374:1617–1625.ArticlePubMed
  • 73. Calafat M, Mañosa M, Cañete F, et al. Increased risk of thiopurine-related adverse events in elderly patients with IBD. Aliment Pharmacol Ther 2019;50:780–788.ArticlePubMedPDF
  • 74. Amano T, Shinzaki S, Asakura A, et al. Elderly onset age is associated with low efficacy of first anti-tumor necrosis factor treatment in patients with inflammatory bowel disease. Sci Rep 2022;12:5324.ArticlePubMedPMCPDF
  • 75. Cheng D, Cushing KC, Cai T, Ananthakrishnan AN. Safety and efficacy of tumor necrosis factor antagonists in older patients with ulcerative colitis: patient-level pooled analysis of data from randomized trials. Clin Gastroenterol Hepatol 2021;19:939–946.ArticlePubMed
  • 76. Borren NZ, Ananthakrishnan AN. Safety of biologic therapy in older patients with immune-mediated diseases: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2019;17:1736–1743.ArticlePubMedPMC
  • 77. de Jong ME, Smits LJT, van Ruijven B, et al. Increased discontinuation rates of anti-TNF therapy in elderly inflammatory bowel disease patients. J Crohns Colitis 2020;14:888–895.ArticlePubMedPDF
  • 78. Yajnik V, Khan N, Dubinsky M, et al. Efficacy and safety of vedolizumab in ulcerative colitis and Crohn’s disease patients stratified by age. Adv Ther 2017;34:542–559.ArticlePubMedPMCPDF
  • 79. Khan N, Pernes T, Weiss A, et al. Efficacy of vedolizumab in a nationwide cohort of elderly inflammatory bowel disease patients. Inflamm Bowel Dis 2022;28:734–744.ArticlePubMedPDF
  • 80. Garg R, Aggarwal M, Butler R, et al. Real-world effectiveness and safety of ustekinumab in elderly Crohn’s disease patients. Dig Dis Sci 2022;67:3138–3147.ArticlePubMedPMCPDF
  • 81. Feagan BG, Sandborn WJ, Gasink C, et al. Ustekinumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 2016;375:1946–1960.ArticlePubMed
  • 82. Sands BE, Sandborn WJ, Panaccione R, et al. Ustekinumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med 2019;381:1201–1214.ArticlePubMed
  • 83. Deepak P, Alayo QA, Khatiwada A, et al. Safety of tofacitinib in a real-world cohort of patients with ulcerative colitis. Clin Gastroenterol Hepatol 2021;19:1592–1601.ArticlePubMedPMC

Figure & Data

REFERENCES

    Citations

    Citations to this article as recorded by  

      • PubReader PubReader
      • ePub LinkePub Link
      • Cite
        CITE
        export Copy Download
        Close
        Download Citation
        Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.
        Format:
        • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
        • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
        Include:
        • Citation for the content below
        Elderly-onset inflammatory bowel disease in Asia: clinical characteristics and therapeutic strategies
        Intest Res. 2025;23(4):430-442.   Published online October 28, 2025
        DOI: https://doi.org/10.5217/ir.2025.00221
        Close
      • XML DownloadXML Download
      Figure
      • 0
      Related articles
      Elderly-onset inflammatory bowel disease in Asia: clinical characteristics and therapeutic strategies
      Image
      Fig. 1. Specific characteristics and therapeutic strategies of elderly-onset inflammatory bowel disease in Asia [14].

      Fig. 1.

      Elderly-onset inflammatory bowel disease in Asia: clinical characteristics and therapeutic strategies

      Epidemiology and Disease Burden of EO-IBD in Asia

      Country Data source Study period No. of patients Elderly-onset group The age at diagnosis (yr) Male sex
      Korea [18,19] The Korean prospective connect cohort study (CD) 2009.1–2019.9 1,175 26 (2.2) 67.5±6.7 14 (53.8)
      A large hospital-based cohort (CD) 1989.6–2016.12 2,989 29 (1.0) 64.5 (62.3–69.6) 11 (37.9)
      Korea [22,32] A large hospital-based cohort (UC) 1989.6–2016.12 3,060 226 (7.4) 65.9 (62.9–68.7) 132 (58.4)
      The population-based cohort (The Songpa-Kangdong, UC) 1986–2015 965 99 (10.3) 66 (62–68) 65 (65.7)
      Japan [15,33] The national database (UC) 2004–2009 28,179 2,778 (9.9) 72.3 (65–92)a 1,692 (60.9)
      A hospital-based cohort (UC) 2006.4–2010.3 343 32 (9.3) NAb NA
      China [34,35] A hospital-based cohort (CD and UC) 2014.1–2021.12 787 184 (23.4)c NAb 82 (44.5)d
      A hospital-based cohort (CD and UC) 1998.1–2020.12 1,609 129 (8.0) 65.2±5.6 84 (65.1)
      India [21] 2 Tertiary IBD centers (CD and UC) 1991.1–2020.12 3,992 186 (4.7) 65.3±15.7e 116 (62.3)
      2016.1–2020.12 65.9±7.6f
      Taiwan [8] The NHI database (CD and UC) 2016–2020 2,595 559 (21.5) NAb NAg
      Hong Kong [20,36] The Hong Kong IBD registry (CD and UC) 1981–2016 2,413 270 (11.2) 68.1±6.7 156 (57.8)
      The Hong Kong IBD registry (UC) 1981–2013 1,225 157 (12.8) NAb 88 (56.1)

      Values are presented as number (%), mean±SD, or number (%).

      aMedian (range).

      bPatients aged 60 years and older were included.

      cIt is uncertain whether these patients represent those who later transition to old age (non-elderly onset) or those diagnosed15 at older age.

      dThis value is an estimate derived from the figure in the main text.

      eThis value corresponds to CD.

      FThis value corresponds to UC.

      gThe male-to-female ratio in the study sample was 1.83:1 for CD and 1.69:1 for UC.

      EO-IBD, elderly onset-inflammatory bowel disease; CD, Crohn’s disease; UC, ulcerative colitis; NHI, National Health Insurance; NA, not available; SD, standard deviation; IQR, interquartile range.

      Comparison of Clinical Characteristics of EO-IBD between Asian and Western Countries

      Characteristics Asia West
      CD
       Common disease location Ileum [18,19,21] Colon [47,49]
       Disease behavior Inflammatory [18,20,21] Inflammatory [27,47,49]
       Perianal involvement Low [18,20,21] (Korea 11.5%, Hong Kong 5.4%, India 5.3%) Relatively low [46,47] (9%–12%)
       Disease course Similar or lower risk of surgery [18,54] Mixed findings across cohorts [58]
      UC
       Common disease extent Proctitis [20,32] (Korea 45.1%, Hong Kong 37.4%) Left-sided colitis [27,49,50]
       Disease course Similar or higher risk of surgery compared with younger onset [15,22,32] Similar or higher risk of surgery compared with younger onset [27,53,58]
      Disease burden of EO-IBD
       Malignancy risk Higher overall malignancy risk [35,39,40] (colorectal, urinary tract, hematologic malignancy) Higher hematologic malignancy risk; overall cancer risk often not increased vs. general population; CRC risk controversioal [41–43]
       Mortality EO-UC higher mortality vs. younger UC [33,38] (Hong Kong: UC-related 7.0% vs. 1.0%; all-cause 1.9% vs. 0.2%; Korea: UC-related 3.5% vs. 0.6%; all-cause 12.4% vs. 1.8%) Generally comparable to background population [41,42,46]
       Hospitalization Higher hospitalization and longer stays [15,20,32]; Some cohorts show similar to younger onset UC (Korea) [21] Mixed findings across cohorts (similar or higher than younger onset) [27,46,52,53,58]
       Infections Higher infection risks [15,32] (e.g., TB, CMV, herpes zoster) Higher infection risks [46]

      EO-IBD, elderly onset-inflammatory bowel disease; CD, Crohn’s disease; UC, ulcerative colitis; CRC, colorectal cancer; TB, tuberculosis; CMV, cytomegalovirus.
      Table 1 Epidemiology and Disease Burden of EO-IBD in Asia

      Values are presented as number (%), mean±SD, or number (%).

      Median (range).

      Patients aged 60 years and older were included.

      It is uncertain whether these patients represent those who later transition to old age (non-elderly onset) or those diagnosed15 at older age.

      This value is an estimate derived from the figure in the main text.

      This value corresponds to CD.

      This value corresponds to UC.

      The male-to-female ratio in the study sample was 1.83:1 for CD and 1.69:1 for UC.

      EO-IBD, elderly onset-inflammatory bowel disease; CD, Crohn’s disease; UC, ulcerative colitis; NHI, National Health Insurance; NA, not available; SD, standard deviation; IQR, interquartile range.

      Table 2 Comparison of Clinical Characteristics of EO-IBD between Asian and Western Countries

      EO-IBD, elderly onset-inflammatory bowel disease; CD, Crohn’s disease; UC, ulcerative colitis; CRC, colorectal cancer; TB, tuberculosis; CMV, cytomegalovirus.

      Table 1

      Table 2

      Intest Res : Intestinal Research
      © Korean Association for the Study of Intestinal Diseases.
      Close layer
      TOP