Managing Acute Severe Ulcerative Colitis in the Older Patient: A Growing Concern

Since the prevalence of older patients with ulcerative colitis is increasing, hospitalizations for severe disease in this age group are expected to rise. Older patients are more likely to present with comorbidities and, consequently, frailty, the latter being one of the major drivers of worse outcomes. The conventional sequencing of therapies in acute severe ulcerative colitis—i.e., intravenous steroids followed, in case of refractoriness, by antitumor necrosis factor (TNF) agents, ciclosporin A, or Janus kinase inhibitors such as tofacitinib or upadacitinib—may frequently be contraindicated in older patients or may carry an increased risk of severe adverse events beyond infections. In the absence of specific guidelines, the implementation of and strict adherence to a structured, time-bound decision tree is essential in order to avoid unnecessarily prolonged treatment with systemic steroids in frail patients, which may lead to deleterious outcomes, particularly in those requiring surgery. Recent reports on adjunctive measures, such as hyperbaric oxygen therapy or total enteral nutrition, may also be considered given their encouraging safety profile.