Management of Inflammatory Rheumatic Conditions in the Elderly
Clément Lahaye; Zuzana Tatar; Jean-Jacques Dubost; Anne Tournadre; Martin Soubrier
Rheumatology. 2019;58(5):748-764.
Abstract and Introduction
Abstract
The number of elderly people with chronic inflammatory rheumatic diseases is increasing. This heterogeneous and comorbid population is at particular risk of cardiovascular, neoplastic, infectious and iatrogenic complications. The development of biotherapies has paved the way for innovative therapeutic strategies, which are associated with toxicities. In this review, we have focused on the scientific and therapeutic changes impacting the management of elderly patients affected by RA, SpA or PsA. A multidimensional health assessment resulting in an integrated therapeutic strategy was identified as a major research direction for improving the management of elderly patients.
Introduction
As a result of increasing life expectancy, risk transition and improved quality of care, the number of people living with at least one chronic disease is increasing.[1] Chronic inflammatory rheumatic diseases (IRDs) affect 2–3% of the general population, involving a non-negligible proportion of elderly subjects. Almost one-third of RA patients are >60 years of age, and elderly patients with IRDs are at particular risk for cardiovascular, neoplastic and infectious complications. Furthermore, IRD in the elderly may have a distinct clinical and biological presentation, with differing responses to treatment.
These features reflect the physiological changes (e.g. immunosenescence and alterations in pharmacokinetics) and comorbidities (diabetes, obesity, renal failure, etc.) associated with ageing, which vary widely from one individual to another.[2,3] Multimorbidity and polypharmacy, both of which are common in the elderly, are well-known risk factors for adverse drug reactions (ADRs) and interactions.[4]
In parallel with this epidemiological evolution, a new class of maintenance therapy agents known as biologics, which comprise specific antibodies with immunomodulating properties, has emerged, thereby expanding the therapeutic arsenal hitherto containing DMARDs, such as MTX, and anti-inflammatory drugs.
Paradoxically, elderly patients have mostly been left out of new therapeutic opportunities. Randomized controlled trials and prospective cohorts primarily recruit healthy or single-disease volunteers rather than elderly and comorbid patients.[5] Thus, the extrapolation of findings to real-life elderly patients may be compromised. Against this background, the novel mechanisms of action of biologics and paucity of literature specifically pertaining to the elderly have raised concerns about the safety of these new drugs, leading to more conventional therapeutic regimens in this population.
Hypothesis and Search Strategy
Several hypotheses guided our study: biologic treatments could benefit both older and younger people; physiological and pathological ageing associated with comorbidities, as well as co-treatment, could partly explain the risk of serious adverse events (AEs) (e.g. infection, cancer, neoplasia, fractures) observed with treatment; and beyond the specific treatments (DMARDs), a more global care strategy could improve outcomes, such as health related quality of life (HR-QoL) and autonomy.
We searched PubMed's MEDLINE and the Web of Science database for studies published over the past 10 years. The search ended in October 2017. Keywords elderly, ageing, aged, recommendations or guidelines were combined with RA, SpA or PsA. The search was limited to articles published in English. The reference lists of relevant articles and conference proceedings were searched manually.
In this overview, we focus on the therapeutic progress impacting the management of elderly with RA, spondyloarthropathy (SP) and PsA, highlighting gaps in the literature concerning this growing, but under-studied, population
Place of the Elderly in the Recommendations
The 2015 Guidelines of the ACR and 2016 EULAR recommendations do not include recommendations regarding the elderly.[16,72] However, comorbidities and safety issues should be taken into account when therapeutic adjustments are required. Specific EULAR recommendations reaffirm the relevance of managing the higher cardiovascular disease risk, not only in patients with RA, but also in those with SA or PsA. The necessity of using NSAIDs and GCs sparingly has also been stressed, [90] but recommendations concerning GC use in elderly RA patients are lacking.
Rheumatology. 2019;58(5):748-764. © 2019 Oxford University Press
SOURCE:
medscape.com/viewarticle/91...
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