Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune, inflammatory disorder that, untreated, can lead to pain, deformity and disability. It affects approximately 1 per cent of adults worldwide with peak incidence in the fourth and fifth decades.
An older person can be affected by RA in two ways – either with longstanding disease throughout their life or by new-onset of joint problems in their older years. Elderly-onset RA (EORA) has become defined as a distinct entity over the last few years. Weight loss at the time of presentation can also occur.
Aging is associated with a state of chronic low-grade inflammation known as inflammaging. The T‑cell repertoire reduces with age making the elderly more susceptible to newer infections. From some research materials I have read I observed that there are varied physiological changes associated with aging, making these patients susceptible to adverse drug effects precluding the adequate use of aggressive immunosuppressive therapy. The presence of comorbidities such as diabetes, hypertension, and atherosclerosis can make the management of these patients challenging.
Rheumatoid arthritis is the most common arthritis condition among the elderly. It is now known to increase in incidence and prevalence up to 85 years of age. The prevalence of Rheumatoid arthritis in adults of 60years is approximately 2%. There is potential heterogeneity among persons with Rheumatoid arthritis.
What is Rheumatoid Arthritis?
Rheumatoid Arthritis is a chronic autoimmune disease characterized by synovial inflammation and joint destruction, whose prevalence increases with age (around 2% in elderly). Rheumatoid Arthritis in elderly can either be elderly onset (EORA defined as onset 60 years) or young onset that persists into older age.
The management of Rheumatoid Arthritis
The management of RA in elderly patients is challenging, since the benefit of treatment should always be evaluated against the comorbid burden and the risk of doing harm due to medication side effects. Several studies described the phenomenon of age bias in the treatment of elderly Rheumatoid Arthritis patients. Age bias refers to the observation that elderly patients receive less intensive treatment compared to younger patients.
Even after controlling for the level of disease activity and number of comorbidities, rheumatologists still preferred the less intensive treatment option in elderly patients. Yet, it is not clear which factors contribute to age bias. For instance, rheumatologists might “adjust” for degenerative joint disease, such as osteoarthritis (OA). On the other hand, RA patients with comorbidity and polypharmacy are likely to have their own beliefs and convictions about the different diseases and medications they have to deal with.
The same pharmacological therapies used in the younger Rheumatoid Arthritis patient can be prescribed in the older person, with regular monitoring and a high degree of vigilance for side effects. None of these therapies will cure RA: remission remains the therapeutic goal.
While usually well tolerated in the short term, longer-term administration may, however, lead to side effects. A higher risk of adverse events has been reported in the older Rheumatoid Arthritis patient, including renal function abnormalities and an increased prevalence of peptic ulcer disease. Secondly, The GI complication risk is increased with the concomitant prescription of anticoagulants or steroids. Much has been published recently on the increased cardiovascular risk with NSAIDs but we should also be aware of the increased prevalence of CNS side effects when prescribing NSAIDs in the older person: psychotic reactions, depression and cognitive dysfunction are reported. In light of this, NSAID use in older people should be minimized wherever possible.
Paracetamol can be used safely if liver function is normal. Caution should be exercised when prescribing opiates or paracetamol and opiate combinations such as cocodamol because of higher rates of constipation and CNS side-effects. Additional laxative prescription may be required.
Steroids are potent suppressors of inflammation in Rheumatoid Arthritis. A brief course of oral steroids can undoubtedly relieve symptoms in the short term, but routine prescription for Rheumatoid Arthritis treatment is not recommended. Older people are at most risk of steroid-related side-effects: diabetes, hypertension, weight gain, bruising, cataracts and osteoporosis. Careful consideration should be given to GI and bone protection with any prescription of steroids. Intra-articular steroids can, however, be extremely helpful in the management of an Rheumatoid Arthritis flare.
Disease-modifying ant rheumatic drugs
Methotrexate is the most commonly prescribed disease-modifying antirheumatic drug (DMARD) worldwide and is the DMARD most likely to induce a long-term response. There is a lack of specific data regarding the use of this drug in older people, but doses of 7.5-25mg per week, with monitoring of full blood count (FBC) and liver function tests (LFTs), remain safe to prescribe.
Methotrexate clearance falls with age and therefore the half life is increased. We would therefore suggest that bloods are strictly monitored and consideration given to using a smaller dose. Studies have shown an increased risk of bone marrow toxicity and CNS disturbance in older people.
Folate supplementation can improve GI tolerability and reduce liver adverse effects – 5mg once weekly is the commonest prescribed regimen. Subcutaneous methotrexate can be considered if there is a suboptimal oral response or if there are concerns over compliance or ability to cope with a more complex therapy.
Sulfasalazine can disrupt liver function, lower white blood cell count and cause a macrocytosis. GI side-effects can be reduced by prescribing an enteric-coated preparation. Some patients, regardless of age, have problems in swallowing the large tablets and consideration should be given to prescribing liquid preparations.
Hydroxychloroquine (Plaquenil) is considered the least potent but best tolerated of the DMARDs. There are no data to suggest that retinal toxicity is any more prevalent in the older RA patient.