SummaryObjectiveIn patients with elderly (≥60 years) onset inflammatory bowel disease (IBD), we studied initiation of medications, drug persistency and surgeries.DesignA nationwide cohort study based on Danish registries, comprising incident IBD patients ≥18 years from 1995 to 2020 (N = 69,039). Patients were divided into elderly (N = 19,187) and adult onset (N = 49,852). Outcomes were initiation of thiopurines, 5‐ASA, biologics and corticosteroids within 1 and 5 years after diagnosis, and for those who initiated medications, we estimated drug persistency. Surgeries were examined within 1 and 5 years. We used regression models controlling for covariates.ResultsIn elderly patients, the adjusted hazard ratios (aHR) for initiating thiopurines, 5‐ASA and biologics within 1 year were 0.44 (95% CI 0.42–0.47), 0.77 (95% CI 0.75–0.79) and 0.29 (95% CI 0.26–0.31) respectively. The results were similar within 5 years. In elderly patients, drug persistency for thiopurines, 5‐ASA and biologics was not impaired within 5 years. The aHR of stopping steroids within 1 and 5 years were 0.80 (95% CI 0.76–0.84) and 0.77 (95% CI 0.74–0.80) respectively. The risk of surgeries was increased in the elderly patients (in ulcerative colitis, within 5 years, aHR 1.39 [95% CI 1.27–1.52], and in Crohn's disease 1.13 [95% CI 1.04–1.23]).ConclusionWe found significantly low chance of initiation of IBD medications in elderly patients, the reason may not be due to mild disease course. In elderly patients, drug persistency was comparable to adults. Clinicians should carefully consider whether they underuse IBD‐specific medications in elderly patients, and special attention should be applied to timely discontinuation of corticosteroids.