Editorial: combination immunosuppressive therapy to treat Crohn’s disease – ready for all age groups? Authors’ reply

We thank Dr. Murray for his interest in our work and comments^1,2. We completely agree that establishing safety of immunosuppressive pharmacotherapy is of paramount importance, especially when treating older patients given the increased susceptibility to infection. Although our study is one of the largest evaluating impact of early combined immunosuppression vs. conventional management over a 2-year period, it was not adequately powered to address safety of different therapies.² In a systematic review, Borren and Ananthakrishnan estimated that the odds of serious infections and malignancy were 2.3 to 3.1-times higher in older patients treated with biologic agents, as compared to younger patients treated with biologic agents.³ However, as noted by Dr. Murrary, within older age patients with inflammatory bowel diseases, specific patient attributes may be associated with increased risk of disease-related vs. treatment-related complications, and for others risk of extra-intestinal, non-inflammatory bowel disease-related complications may dominate.⁴ Treatment would ideally be tailored to specific patient risk attributes, including both risk of disease-related vs. treatment-related complications. Future studies need to evaluate the appropriate older patients for whom a strategy of early combined immunosuppression would be effective and safe. Furthermore, these should also be evaluated in the context of novel therapies which have differing safety profiles to anti-TNF therapy.