Reply to Letter from Dr. Asscher and colleagues

We thank Dr. Asscher and colleagues for their interest in our work and for their comments.¹ We welcome their recommendation for more evidence to help inform the management of older patients with inflammatory bowel disease (IBD) in daily clinical practice. We completely agree that frailty is not a binary state, and exists as a spectrum, with impairment potentially impacting multiple domains to varying extent (somatic, mental, functional and social status). Our intent was to highlight the distinction between chronological age and fitness, in determining optimal management strategies. We agree that a comprehensive and structured assessment of frailty be routinely considered in the management of older patients. With regard to our proposed pharmacological management of older patients with IBD, we acknowledge that this represents our opinion, based on our interpretation and extrapolation on the comparative efficacy and safety of pharmacotherapies.² Though studies have not directly compared the biologic monotherapy vs. methotrexate monotherapy, indirect comparisons suggest that biologic therapy may be more effective than methotrexate monotherapy for inducing and maintaining remission.³ Future studies to better inform evidence regarding the safety and tolerability of therapies specifically in older adults are both warranted and welcomed.